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 responsibility of the medical
biller in a health care facility is to follow that claim to ensure the practice receives reimbursement for
the work the providers perform. A knowledgeable biller can optimize revenue performance for the
practice.

Although a medical biller’s duties vary with the size of the work facility, the biller typically assembles
all data concerning 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 clarify diagnoses or to obtain additional information. Therefore,
the medical biller must understand how to read the medical record and, like the medical coder, be
familiar with CPT®, HCPCS Level II and ICD-9-CM codes.

INTRODUCTION OF GOVT. INSURANCES

A-Federal Insurance:

1. Medicare

2. Medicaid

3. Tricare

4. RR Medicare (RR-Rail Road)

Medicare Eligible:

Administered by and directly the federal government.

1. People 65 Years above

2. People Under 65 with certain Disabilities

For People with Disabilities and Illnesses:

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 can get
Medicare benefits. Here are the details.

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 you've
been diagnosed with kidney failure, call the Social Security administration at (800) 772-1213 to enroll
in Medicare.

Other disabilities for which you get Social Security Disability benefits: You can't get Medicare until
two years after you qualify for Social Security Disability. At that point, the Social Security
Administration should sign you up automatically.
Note: Patient must be Tax Paid in order to get Medicare benefits.

The Different Parts of Medicare:

1. Part A

2. Part B

3. Part C

4. Part D

Part A (Hospital Insurance):

• Only Covered with Hospital Services (Ex. Bed Charges & Equipment charges)

• It Covers Inpatient care in Hospital.

• It covers Skilled Nursing facility, hospice and home health care.

• Claims billing to UB92 & UB04 forms.

Part B (Medical Insurance):

• It's Covered with Doctors' Services, hospital outpatient care and home health care.

• It covers some Preventive services to help maintain your health and to keep certain illness
from getting worse.

• Claims Billing to HCFA-1500 & CMS1500 forms.

Part C (Part A + Part B + Part D):

• Medicare Advantage plans (like an HMO or PPO) are health plans run by Medicare-approved
private insurance companies. Medicare Advantage plans (also called Part D) include Part A,
Part B and usually cover things like Medicare prescription drug coverage (Part D), sometimes
for an extra 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 = retired worker
B = wife of retired worker
B1 = husband of retired worker
B6 = divorced wife
B9 = divorced second wife
C = 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 = wife 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 B Medicare, no SSA benefit
W = disabled widow
WA = railroad retirement
*denotes the recipient’s own social security number.

Medicaid:
It’s covered with below Poverty people (or) Low-income people. It’s monthly month basic.
Administrated by Each State Law.

Tricare:
It’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 Medicare:
It’s covered with Railway Department, Transport Department & Highway's Department.

Worker's Compensation:
It’s covered with work-related injury and work-relevant accident.

Auto Accident:
It’s covered with vehicle accident.

Two Types of Auto Accident:

1. No Fault Auto Accident

2. Non-Fault Auto Accident

Managed Care Plans:

To provide high quality service at low cost.

1. HMO (Health Maintenance Organization)

Patient must go to in-network provider. PCP must (low premiums, low deductible, copay &
coins). PCP means Primary Care Physician.
Pt goes to PCP first and PCP issues referral for specialist visit according to diagnosis.

2. PPO (Preferred Provider Organization)

Patient may go 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
 healthcare providers - that participate in the plan. The only exception is for emergency care.
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 combined with HMO-PPO. Patient may go to any network provider (In or Out). PCP must.

Traditional Indemnity:

Patients are billed and repaid for all or part of each service performed, subject to deductibles and
limits on coverage.

COBRA:

The term COBRA is an acronym for the Consolidated Omnibus Budget Reconciliation Act of 1986—
federal legislation that governs the extension of group-sponsored health plans of Businesses with
twenty or more employees. The COBRA Plan will offer continuing healthcare coverage to you and
your dependents if you leave your job. You will have to pay the entire COBRA premium on your own,
however. It’s possible to extend COBRA’s Coverage for up to 18 months and a surviving dependent
can 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 account. 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 called a high-deductible
plan.

PAR Provider: (Participating Provider)

Who agrees and accepts Insurance fees schedule and is willing to contract with the Insurance
company.

Capitation:

1. Fixed Capitation

2. Rolling Capitation

i. Fixed Capitation:
Provider will get fixed amount for every month/year.

ii. Rolling Capitation:

Provider will be getting the fixed amount for every patient.

Non-PAR Provider (Non-Participating Provider):

Who does not contract with any Insurance company. (no write-off).
Medical Terminology

Coinsurance:
Portion/Fixed Percentage of the Allowed amount, insured/subscriber/Patient has to pay to the
Healthcare Provider.

Copay:
It’s fixed amount payable to provider by insured for each visit.

Deductible:
A specified amount of money that the insured must pay before an insurance company starts benefits.
Medicare & Commercial 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 annum Deductible Amount - $147.00

Authorization:

Two types of Authorization:

1. Prior Authorization

2. Retro Authorization

Prior Authorization:
The process of obtaining permission to perform a service from the insurance carrier before the
service is performed is called Pre-authorization. Prior authorization is only required for certain types
of procedures or specialty. However, prior Auth is not a guarantee of payment.

Retro Authorization:
After 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 receive services when
Medicare/Medicaid is not expected to pay for some or all of the services.

AOB (Assignment of Benefits):

Patient assigns benefits to the provider behalf of the treatment.

COB:
Coordination of Benefits; it’s deals with primary and secondary insurance.
SSN (Social Security Number):
Number that all U.S. Citizens must. This number is given by Social Security Administration. SSN 3-2-4
format. First 3-digit-Area Code 2-digit-Group no. 4-digit-Serial no.

Allowed Amount:
Insurance Company fixed Maximum amount allowed each and every procedure code is called
Allowed amount.

Refund or Take Back:

Claim wrongly processed and paid to the provider after the insurance company find the amount and
ask refund request from the provider.

Offset or Recoupment Amount:

It the provider not refund the amount 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 describe 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 and/or in more than one
location.

• A service or procedure has been increased or reduced.

• Only part of a service was performed.

• A bilateral procedure was performed.

• A service or procedure was provided more than once.

• Unusual events occurred.

 1. Information Modifier

2. Reimbursement Modifier

1. Information Modifier:

Does not vary the payment; just intimate the insurance company which part of the organ service was
rendered e.g. LT, RT, AI, KX, K0.

2. Reimbursement Modifier:
Vary the payment who render the service patient (EX) PC, TC, 24, 25, 26, 59, 78, 79.

Commonly Used Modifiers:

• 24: 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 of a Procedure or Other Service.

• 26: Reading of Reports.

• 50: Bilateral Procedure.

• 57: Decision of Surgery.

• 58: Staged or Related Procedure or Service by the Same Physician During the Postoperative
Period.

• 59: Distinct Procedural Service.

• 76: Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a
procedure or service was repeated subsequent to the original procedure or service.

• 77: Repeat Procedure by Another Physician: The physician may need to indicate that a basic
procedure or service performed by another physician had to be repeated.

• 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 Period: The physician
may need to indicate that the performance of a procedure or service during the postoperative
period was unrelated to the original procedure.

• 90: Reference (Outside) Laboratory: When laboratory procedures are performed by a party other
than the treating or reporting physician, they are to be identified by adding the modifier 90 to
the usual procedure number.

• 91: This modifier may not be used when tests are rerun to confirm initial results; due to testing
problems with the specimens or equipment; or for any other reason when a normal, one-time,
repeatable result is all that is required.
CMS:
Canters of Medicare and Medicaid Service

HIPAA:
HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed 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 indicates where the service was rendered. (EX) Hospital, Clinic, Home, etc.
Most commonly used POS are mentioned below.

• 11 - Office

• 12 - Home

• 13 - Assisted Living Facility

• 20 - Urgent Care

• 21 - Hospital In Patient

• 22 - Hospital Out Patient

• 23 - Emergency Room

• 31 - Skilled Nursing Facility

• 32 - Nursing Facility

• 81 - Independent Laboratory

ROI: (Release of Information)

Patients accept agree to release their Medical Information

DX-Codes: (Diagnosis Code) (ICD9 or ICD10 codes)

The identification 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 physicians, health insurance companies and accreditation organizations.

There are three types of CPT codes. Category 1 covers evaluations, Category 2 deals with
performance measures, and Category 3 covers emerging technologies, services, and procedures. The
most current edition is CPT 2010.

HCPCS level-1 codes:

CPT Code means Procedure code. 5-digit number.

1. E/M (Evaluation Management) Visit. Starting with 99201-99499.

2. Anaesthesiology – Starting with 00100-01999, 99100-99140

3. Surgery – Starting with 10021-69990

4. Radiology (Including Nuclear Medicine and Diagnostic Ultrasound) (Ex: Ex ray, CT, MRI) –
Starting with 70010-79999

5. Pathology (Blood test, Urine test) – Starting with 80048-89356

6. Medicine (except Anaesthesiology) (EKG (ECG), EMG) – Starting with 90281-99199, 99500-
99602

HCPCS Code:

Health Care Financing Administration Common Procedure Coding System (pronounced "hick-picks").
Three level system of codes.

Level I - American Medical Associations Current Procedural Terminology (CPT) codes.

Level II - The alphanumeric codes which include mostly non-physician items or services such as medical
supplies, ambulatory services, prosthetics, etc. These are items and services not covered by CPT (Level
I) procedures.

Level III - Local codes used by state Medicaid organizations, Medicare contractors, and private insurers
for specific areas or programs.

Pre-Existing Condition:

Patient already suffered from some disease before the policy. Insurance will not cover the condition
for that disease, that patient responsible... that period called "Waiting Period". EX: Heart Disease, High
blood pressure, Cancer and more.

FECA - Federal Employee's Contribution Act.

The Federal Employees' Compensation Act (FECA) provides federal employees injured in the
performance of duty with benefits. This act provides benefits to injured federal workers and their
survivors. The benefits are administered by the Office of Workers' Compensation Programs (OWCP).
Work on Claim:

1. Eligibility verification

2. Pt. id/group number, effective/Termination date, claim mailing address, payer ID or fax,
Timely filing limit

3. Billing entry

4. Reconcile

5. Claim submission: Paper, Electronic, Fax or Online on Web portal

6. Call after appropriate days of filing for claim status

7. If not on file, verify eligibility again

8. If deny, detail reason agrees about this denial and try to reprocess if you see any possibility

9. If paid, get received date. Paid date, check#, claim# and the address where they mailed the
check. Date of check cleared.

10. Payment posting... and work on denial.

11. Appeal on those denials which you feel denied in error/Fault of Insurance company or
Medical Necessity.

Skills/Experience:

1. Good communication/Listening Skills (English)

2. Knowledge of medical billing/collection practices.

3. Knowledge of computer programs and basic office equipment.

4. Knowledge of business office procedures.

5. Knowledge of basic medical coding and third-party operating procedures and practices.

6. Ability to operate a multi-line telephone system.

7. Ability to maintain a pleasant and helpful manner.

8. Ability to understand and follow oral and written instructions.

9. Ability to establish and maintain effective working relationships with patients, employees
and the public.

10. Must be well organized and detail-oriented.

DAILY USE ABBREVIATIONS:

• NPI - National Provider Identifier

• TIN - Tax Identification Number

• IVR - Interactive Voice response

• EOB - Explanation of Benefits

• DMEE - Durable Medical Equipment

• HIPAA - Health Insurance Portability and Accountability Act

• CLIA - Clinical Laboratory Improvement Amendments

• EDI - Electronic Data Interchange

• EGHP - Employer Group Health Plan

• EIN - Employer Identification Number

• ERISA - Employee Retirement Income Security Act

• ESRD - End Stage Renal Disease

• HCFA - Health Care Financial Administration

• HIC - Health Insurance Claim

• HCPCS - Healthcare common procedure coding system

• ICD9CM - International Classification of Disease 9 the revision of clinical modifier

• DOS - Date of Service

• OWCP - Office of Workers' Compensation Program

• PIN - Provider Identification number

• PCP - Primary Care Provider

• ERA - Electronic Remittance Advice

• RA - Railroad Retirement Board

• SSA - Social Security Administration

• SNF - Skilled Nursing Facility

• TPA - Third Party Administrator

• UPIN - Unique Physician Identification Number.

EVALUATION AND MANAGEMENT CODES (Commonly Used)

POS LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVELS DESCRIPTION

99201 99203 99204 99205

11 99202 20mins OFFICE NEW VISIT
10mins 30mins 45mins 60mins

99211 99213 99214 99215

11 99212 10mins SUBSEQUENT
5mins 20mins 30mins 45mins

99341 99343 99344 99345 CONSULT ASSISTED LIVING

13 99342 20mins
15mins 30mins 45mins 60mins HOME/NEN

993481 99383 99384 99385 SUBSEQUENT

21 99382 25mins
15mins 35mins 45mins 60mins HOSPITAL/INITIAL VISIT

99231 99233 99234 99235

99232 25mins FOLLOW UP
15mins 35mins 45mins 60mins

99251 99253 99254 99255

99252 40mins CONSULT
20mins 55mins 80mins 110mins

99291 30- 99292 each

22 99293 99294 99295 HOSPITAL CRITICAL CARE
74mins additional 30

99294 SAME DAY OBSERVATION

99324 99326 99327

22 99325 30mins 99328 INITIAL OBSERVATION
20mins 40mins 60mins

99217 FOLLOW UPS

23 99281 99282 99283 99284 99285 DISCHARGE

EMERGENCY SKILLED
99301 99306 99310
31 99305 30mins 99318 NURSING FACILITY INITIAL
25mins 45mins 60mins
VISIT

99309
99330 35mins 99340 SUBSEQUENT
25mins

99381 3-
11 99382 12-17 99383 PHYSICAL EXAM New
11yrs

99394 ESTABLISHED
Collector Must Know (After above short training)

• 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.

• Must Know BASIC process of Credentialing.

• Must Know to work on web portals.

• Must Dial 50 calls to Hospital/Provider’s, Insurance Companies and Patients.