CHAP #01 & 02 Introduction to medical Billing

 Medical billing is the process of submitting and following up on claims submitted

to insurance companies in order to receive payment for services rendered by a
Healthcare Provider.
 The purpose of medical billing is to ensure that the provider receives fair
payment for services rendered. Payment should reflect the services performed
and should be receive in a timely manner.
 This process is also called RCM (Revenue cycle Management).
WHY DOCTORS HIRE MEDICAL BILLER
 Creating claims and reimbursed by the insurance companies is such a lengthy
process.
 Doctors or facilities want to utilize their precious time to handle patients only
do not want waste it on documentation and other clerical things.
WHAT IS THE SCOPE IN THIS PROCESS?
 One of the fastest growing industry in the world.
 Experience and knowledge matter
 New learning everyday
BASIC TERMS
1. Guarantor/ subscriber
 The person who has the insurance policy is Guarantor/Subscriber. A patient
visiting the doctor may be covered under someone else policy. Like child or
spouse under husband policy.
2. Practice
 A place where the services are performed. Sometime it is same as Doctor name.
3. Patient Demographic
 Some specific information that needs to create a patient account in Doctor’s
System. Such as name, sex, address, phone, dob, and insurance information.
4. PCP (Primary Care Physician)
 A doctor who see the patient for the first time for a disease or illness and refer
it to a specialist. Some kind of insurance plans must require a PCP. Family doctor.
5. Specialist
 The doctor who are specialize to treat a particular type of disease or organ. Like
Cardiologist, Pediatrician etc.
6. Referral
 Some insurances plan requires a referral from the PCP before seen by a
specialist. Specialist needs referral form the patient PCP.
7. Authorization
 Imagine you're planning to have a big medical procedure, like surgery or a
costly test. Before you go ahead with it, your healthcare provider needs
permission from your insurance company. This permission is called
"authorization." Without taking prior authorization claim can be denied.

CHAP #03 What is Deductible, Copay and Coinsurance

1. Policy/ Plan Maximum

 Money your insurance pays for your medical bills within a specific time
frame, like a calendar year.
2. Patient Responsibilities
 Patient Responsibilities are the costs you're expected to pay directly for your
medical care. This could include things like copayments, coinsurance, and
deductibles.

Types of Patient Responsibility

 Deductible (PR-1)
It is the fixed amount that need to be paid by the insured or subscriber to the
provider before actual policy benefits starts.
 Premium:
The premium is the amount you pay regularly (usually monthly) to keep your
health insurance coverage active.
Example: Let's say your health insurance premium is $200 per month. You'll pay
this amount regardless of whether you use any medical services.
 Copayment (PR-3)
Copays are flat fees for certain visits. It is a fixed amount that need to be paid
by policy holder directly to the provider before each visit/encounter.
 Co-insurance (PR-2)
Coinsurance is the percentage of the bill you pay after you meet your
deductible. This amount is a percentage of the total cost of care—for example,
20%—and your Blue Cross plan covers the rest.
 Co-insurance VS Copay (usually assign after claim processing)
coinsurance is not the same as copay. A copay is fixed amount you're charged
for prescriptions, doctor visits, and other types of health care—generally at the
time of service. Your copay applies even if you haven't met your deductible yet.
Many insurance companies operate on an 80/20 coinsurance plan.

CHAP #04 What is ICD, CPT and Modifiers

What is CPT (Procedure Code)?
 It is current Procedure Terminology. And maintained by AMA (American Medical
Association).
 CPT Codes are 5-digit codes that maybe alphanumeric or numeric codes with
descriptive terms for reporting medical services and procedures performed by
doctors.
 CPT code is also called Procedure codes. Most of these codes are solely numeric,
but a few have a letter as the first digit.
What is ICD (diagnose code/ DX Code)?
 It is called International Classification of diseases. It is Maintained by WHO –
World Health Organization.
 Presently 10th revision which is called ICD10. Nowadays we are using ICD10 in
our claim after 2015.
 ICD is a system used worldwide to classify and code diagnoses, symptoms, and
medical conditions.
 It provides a standardized way for healthcare professionals to record and track
diseases and health-related problems.
 These codes are alphanumeric and 3 to 7 character long. And ICD is used
Globally all over the world.

What are Modifiers?

 Modifiers are two digit codes. It could be totally numeric, Alphabetic or
Alphanumeric. Always used with procedure/ cpt codes.
 A modifier is a code used in medical billing to provide additional information
about a service or procedure performed by a healthcare provider. It helps
describe specific circumstances or variations that may affect reimbursement.

CHAP #05 What is Fee Schedule, NPI & Tax ID

What is Fee Schedule?
 It is a complete listing of fees used by insurance to pay providers according to
services performed.
What is NPI?
 It is a 10-digit unique identification number allocated to Doctors & facilities. It
is compulsory to obtain NPI for doctors & facilities.
What is Tax ID?
 Tax identification number is used by IRS for tracking purpose. Basically used to
track transactions.
 IRS is income tax department of US.
In-Network Provider:
 In-network provider is a healthcare provider or facility that has an agreement
with your insurance company to provide medical services at pre-negotiated
rates. These providers are part of your insurance plan's network.
Out-of-Network Provider:
 Out-of-network provider is a healthcare provider or facility that does not have
a contract with your insurance company. Visiting an out-of-network provider
may result in higher costs for you because they do not have pre-negotiated rates
with your insurance plan.
CHAP #06 Medicare, Medicaid, PPO, HMO and Various common insurances
In US most of people must have insurance. About more than 80 percent have health
insurance. Many insurance companies operate in USA. But most of the peoples
have Government insurance.
Government Insurances
Medicare
 Federal government program that provides health care coverage.
Eligibility
1. A person should have more than 65 years’ age (US citizens) or person has
paid tax for 10 years.
2. Person have any disability recognized by RRB
3. Person should have ESRD (End stage renal disease)
Medicare Parts
1. Part A [ Hospital Coverage]
2. Part B [Medical Coverage]
3. Part C [Part A + B + D]
 It is also called Medicare Advantage Plan.
4. Part D [Drug Prescription]
Note: When patient will be eligible for Medicare, by default he will be given Part A
and Part B. Patient will have to pay some charges if he wants to use Part C or Part
D.
Q. When Medicare will be a secondary payer.
In following conditions Medicare will be a secondary payer.
MSP means Medicare Secondary payer.
Conditions
1. Patient has worker compensation
2. Patient has group health plan
3. If patient has auto/ no fault injury
Medigap
 Medigap is a supplement plan of Medicare it only pays left out amount by
Medicare. For example, ARP.
  Example: Medicare allowed 100$, and pay 80$, so left amount co-insurance
20$ will be paid by Medigap.
Inpatient
 When a patient is hospitalized more than 24 hours of time.
Outpatient
 When a patient is hospitalized less than 24 hours.
Federal insurances
- Medicare, Medicaid, Tricare, Rail Rode
Commercial Insurances
 United health care (UHC), BCBS, Cigna, Aetna, Megna Care
Note:
- A person will be need a certificate to prove that his income is below poverty level.
And he must have to renew the certificate after every 6 months.
Medicaid
- Medicaid is run by state.
Medicaid Criteria
1. Low income peoples
2. Pregnant women
3. Disable Peoples
4. Old age peoples
Note: If patient have more than one insurance in that case Medicaid will always
pay on last.
- Medicaid is month to month plan where the subscriber has to show income
month to month, if any month patient will be failed to show his income then he
lost the coverage by Medicaid.
BCBS
 US has total 50 States. And BCBS cover almost all states. BCBS has following two
plans:
Scenario:
If patient purchase plan in a state of New York, and late on he shifted in new
jersey state, so he does not need to go New York for services, he can just directly
take services from new jersey.
 1. BCBS Home
 when the service is rendered within the patient city is called home plan.
2. BCBS Host
 When service is rendered outside of the patient city is called host plan.
Note: AR department always will contact with host plan.

COMAPRISON B/W ALL PLANS

Primary Care Physician (PCP) Requirement:
HMO: Requires choosing a PCP from the network and obtaining referrals for
specialists.
PPO: Does not require a PCP or referrals; you can see specialists directly.
EPO: Does not require a PCP or referrals; you can see specialists directly.
POS: Requires choosing a PCP from the network and obtaining referrals for
specialists within the network.
In-Network vs. Out-of-Network Coverage:
HMO: Limited or no coverage for out-of-network services, except for
emergencies.
PPO: Offers coverage for both in-network and out-of-network services, with
higher costs for out-of-network care.
EPO: Limited or no coverage for out-of-network services, except for emergencies.
POS: Offers coverage for both in-network and out-of-network services, with
higher costs for out-of-network care.
Referrals for Specialists:
HMO: Requires referrals from PCP for specialists within the network.
PPO: Does not require referrals; you can see specialists directly.
EPO: Does not require referrals; you can see specialists directly.
POS: Requires referrals from PCP for specialists within the network.

1. Allowed Amount
Paid amount+ Patient responsibility
2. Billed Amount
Allowed Amount + Adjustment
3. Paid Amount
 allowed amount - Patient responsibility
4. Patient Responsibility
allowed amount – paid amount
5. Adjustment Amount
Billed amount – Allowed amount
6. Rejected Amount
allowed amount – Paid amount

CMS
 CMS means center of Medicare and Medicaid services. It is a department of health
and human science which concentrate on Medicare and Medicaid program.
 All the insurance companies and provider follow the instructions and guidelines of
CMS.
 CMS decide the charges for any service etc.

CHAP #07 US Healthcare Process Flow Physician Office

1. Appointments/ Scheduling
2. Front desk (Reception)
 Ins card scanning
 Copay collected
3. Demographic Entry
4. Encounter
Patient seen by doctor and treatment/consultation done.
5. Medical Transcription/Scribe
Voice file is converted to medical record
6. Medical Coding
Cpt & Diagnosis codes are confirmed and coded.
7. Claim Billing
Billing team posted claim in system.
8. Copay posting
9. Claim inspection/ Filing
10. EDI corrections
Minor issues corrected and clean claim is processed.
11. Payment Posting / Denial Posting
12. AR Follow up
13. Patient Billing
14. Collections
moved towards collection agency if not collected within specified time.

CHAP #08 Evaluation & Management Services

1. New Patient:
A new patient is one who has not received any professional services from the
provider of the same specialty in the same group within the past three years.
CPT Codes: 99201- 99205
2. Established Patient
A new patient is one who has received any professional services from the
provider of the same specialty in the same group within the past three years.
CPT Codes: 99211- 99215
3. Emergency Services
Unscheduled Services received under Emergency department of a hospital for
immediate medical attention (within 24 hours).
CPT Codes: 99281- 99285
4. Observation Services
Services received under observation department of a hospital to observe the
condition of the patient. (usually 72 hours).
CPT Codes: 99217-99226
5. Inpatient Services
Services received under inpatient department of a hospital to treat patient’s
condition for a longer duration. (More than 72 hours)
CPT Codes: 99221, 99223,99238,99239

These are not all, there are so many categories of E&M. we just discussed the
most important.
CHAP #09 AR (Account Receivable)

What happen when a claim is denied?

 When a claim is denied by insurance company then it is account receivable
department duty to fulfil the requirements of the paper.
 We work on that claims on priority basis who’s will be denied for any reason
from insurance.
 Sometime claims are denied and in some case claims are not responded by
insurance.
 There could be several reasons when a claim is denied by paper, so a person
who will be familiar with the most of those reasons he considers more
competent and get promotions accordingly.
 Working on denied claims along with the claims which have no
correspondence with the insurance is called AR.
 Usually insurance company respond against the claim, within 30 days, if he
will not respond within 30 days, then in that case we will contact insurance
company that why the claims are not paid.

Most common Denials

 Claim is not on file
It means that you were send claim to company and after waiting 30 days you
contact with insurance company and came to know that claim is not received by
the payer. Then it is called claim is not a file.
In that case following things should be keep in mind when payer is saying claim is
not on file.
 Electronic Claim [Take 3- 7 days to reach]
 Paper claims [Takes 15-30 days to reach]
Note: if claim has passed these days and still no payment or denial is received, then
we will call to insurance company or verify claim status on web portal.

If Paper claim is not on file

1. Confirm patient Eligibility
Incase if paper claim is not on file then first of all we will check whether the
patient is eligible for the insurance or not?
 2. Confirm Provider’s Participation status
When we talk about confirming the provider's participation status, we're
checking whether the healthcare provider (the doctor or medical facility) is
actively participating in the patient's insurance network.
3. Confirm mailing address
Usually we can check it from the back side of patient insurance card. We can
check mailing address if claim is going to be sent through paper submission and
we can check payer id if claim is going to send through electronically.
4. Confirm Payer Id if any

5. Confirm fax number if any

 Fax is the fastest process for sending claims. We will directly call the insurance
company, and ask for fax number and claims and all necessary documents will
be send through fax.
Note: But usually insurance companies does not encourage this method.

Reasons
1. Security Concerns:
Faxing involves sending sensitive patient information over traditional telephone
lines, which may raise security concerns. Electronic methods often use secure,
encrypted channels, providing a more secure way to transmit patient data.
2. Integration with Systems:
Electronic submissions seamlessly integrate with the systems used by insurance
companies. They can be automatically processed and entered into the payer's
claims processing system, streamlining the workflow.
3. Cost Savings:
Electronic submissions can lead to cost savings for both healthcare providers and
insurance companies. The manual handling and processing of paper documents, as
seen with faxed claims, can be more resource-intensive and costly.

If Electronic claim is not on file

We can check the following if electronic claim is not on file.
1. See if any EDI rejection
EDI (Electronic Data Interchange)
It is the most important error to understand, we didn’t wait for 30 days in case, we
usually check it in 24 hours.
2. Confirm Patient Eligibility

3. Confirm Provider Participation status

4. Confirm mailing address

5. Confirm payer ID
We usually confirm payer id from the back of patient card, or you can directly call
the payer for the confirmation of payer Id.
6. Confirm fax number if any
Fax is the fastest process for sending claims. We will directly call the insurance
company, and ask for fax number and claims and all necessary documents will be
send through fax.
CHAP #10 Methods of claim payment

1. Claim is paid by EFT:

Let you we call a company to check the status of claim, and they told us the claim
is paid by EFT (Electronic Fund Transfer). In EFT insurance directly process payment
in doctor or clinic account electronically. So now we need to post that claims in our
system, then that claim will be considered closed.
These are the following things that we need to confirm in case of paid claim:
1. Paid Date
We confirm the payment date issue by payer.
2. EFT Number
The EFT number is a unique identifier associated with an Electronic Funds Transfer
transaction. It is used to track and identify electronic payments.
3. EFT Bulk amount
When we send a bunch of claims (let's say 20) to the insurance company, they don't
pay each claim one by one. Instead, they process all of them together in a bulk
payment.
We also need to make sure we post the total amount from this bulk payment in our
own system.
4. Allowed amount per line
Each CPT has its own allowable amount. Insurance have fixed fee schedule for each
procedure. Insurance only allow that specific amount according to fee schedule
which is called allowed amount.
5. Paid amount per line
It means if you bill 3 different CPT codes in one claim, so in that case you will be
need to take allowed and paid amount for each CPT code line-wise.
6. Patient Responsibility
You will be need to confirm patient responsibility on each line of claim means for
each CPT code. Patient responsibility maybe deductible, co-insurance, copay etc.
Example:
Billed $120
Allowed $100
Paid $60
PR $40
We must need to confirm all these amount on a paid claim.
Fee-for-Service vs. Capitation:
In fee-for-service models, providers are paid for each service rendered. In
capitation models, providers receive a fixed amount per patient regardless of the
services provided. The fee schedules may differ based on the payment model.

2. Claim is paid by Check

We will be required following information if claim is paid through check.
1. Check issue date
2. Check Number
3. Check Bulk amount
4. Allowed amount per line item
5. Paid amount per line item
6. Patient responsibility
7. Check cashed date
When check in cashed, it will be reflecting in doctor bank statement.
8. Check mailing address
9. If the check is mailed on different address, then we will stop the payment
request for reissue.
10.Will take process to update correct address

3. Claim Directly paid to Patient

Note: In some cases, insurance directly paid to patient rather than provider, in that
case we will billed all amount to patient and then patient will have to pay that
amount to doctor directly.

4. Claim is paid by Credit Card

Imagine you submitted a medical claim, and the insurance company decides to pay
you using a credit card. Here's what you need to know:
1. All payment detail
The insurance company provides you with all the payment details. This includes
the total amount paid, the date of the payment, and any relevant transaction
information.
Example: You submitted a claim for $500, and the insurance company paid you
on January 15, 2024, using a credit card. They confirm the payment details,
including the total amount.
2. Virtual Credit Card
 Insurance companies issues virtual credit card on paper. In this case insurance
provide us EOB, and on EOB we will have a picture of virtual credit card.
Credit card numbers typically contain 16 digits.
 First Six Digits (Issuer Identification Number - IIN):
 Digits 7 to 15 (Account Number):
 Final Digit (Check Digit):

Instead of a physical credit card, the insurance company may use a virtual credit
card for the payment. A virtual credit card is a digital version that contains the
necessary details for a one-time transaction.
Example: You receive a virtual credit card number (a series of digits) from the
insurance company for the $500 payment.
3. Expiry Date
Like a regular credit card, a virtual credit card has an expiry date. It's essential
to note this date as the card won't be valid for transactions after it expires.
4. CVV number
The Card Verification Value (CVV) is a three-digit security code on the back of a
physical credit card. For virtual credit cards, the insurance company provides a
corresponding CVV number for security.
5. Bulk number
Sometimes, insurance companies process payments in bulk, meaning they
might pay multiple claims at once using a single credit card transaction. The bulk
number helps identify this collective payment.
Example: If the insurance company processed payments for several claims
together, they provide a bulk number (e.g., B123) for reference.
Note: Provider can deduct amount from virtual credit card issued by insurance.
Normally we will get all this information from insurance on call by providing our
provider details. And this is the fastest way for doing claim payment.
CHAP #11 Commonly used Modifiers

Modifiers are very important in AR because whenever we receive a denial, in most

of the cases we can correct denial by using sufficient modifiers.

Frequently Used Modifiers

1. Modifier 22
 Increased Procedural Services (Surgical/procedure codes only). If you are
working on any claim, and on that claim modifier-22 is appended, it means
provider give an extra time for procedure as compare to usual time require for
that services.
 For Example, if a patient visits the doctor for any surgical procedure and doctor
take more time as compare to usual procedure and now he wants a
reimbursement for this extra time given to patient, then in that case provider
can use Modifier 22 which will represent an extra time is given to patient for
any certain procedure.
Note: In most of the cases, if we use Modifier 22 in that case insurance may be
required medical record to ensure which extra service is performed by provider.

2. Modifier 24
 Unrelated E/M service by the same physician during the postoperative period.
Scenario: If patient take a treatment from the provider for a specifier disease,
and after 2 or 3 days he came again for treatment of same disease in that case
provider can’t bill for that disease in global period again.
Solution: If you want reimbursement in this case, then you will have to give a
proof that the services provided again to patient is unrelated to previous. And
you can only prove it using Modifier 24, that will represent that unrelated
procedures are performed.
Note: If claim is denied due to global period, and that claim is regrading E/M in
that case you will have to check that in previous visit of patient what was the
primary diagnosis code and then will you check the claim which is now denied,
if Modifier 24 is not appended in this denied claim, just append 24 modifiers
with CPT.
3. Modifier 25
 Significant, separately identifiable Evaluation and management (E/M) services
by the same physician on the same day of a procedure or other services.
 Example: ye tab lagta hai jab docot doctor E/M k sath koi minor procedure
perform kar raha ho ya injection waghira laga raha ho.

 Patient visits the provider for hedic, doctor consult the patient and spend 10 or
20 minutes with patient, then patient said that he also has pain in leg, doctor
suggest for x-ray, and also give injection for pain. Now actually doctor perform
three services. Now doctor must need to append Modifier 25 with Evaluation
and Management CPT.
 Modifier 25 is used to unbundle the services if more than one services are
provided in office setup or hospital setup.
 Denial code maybe CO-97, TR-97 etc.

4. Modifier 26/ TC
 Professional or Technical Components only, here professional mean if doctor is
reading laboratory report, and technical means laboratory equipment’s are
used.
 Used for reading of reports. It is usually billed for radiology services.
 Example: Patient visits the provider for hedic, doctor consult the patient and
spend 10 or 20 minutes with patient, then patient said that he also has pain in
leg, doctor suggest for x-ray, and also give injection for pain.
 now if you are billing on behalf of doctor then you will use Modifier 26, and if
you are billing on behalf of radiology center/ LAB etc. for using technical
component then you will use TC modifier.
IMP NOTE: In-case if in a provider office setup, provider have X-Ray machines
and itself he is reading a reports then no modifier will be appended. Usually
radiology services codes are start with 1700 series.

5. Modifier 50
 Used for Bilateral procedure. Bilateral means on both sides.
Example: If procedure is performed on patient ear, then we need to clarify that
on which side the procedure is performed. If procedure is performed on right
side then we will use RT, and in-case of left side we can use LT. but if procedure
 is performed on both sides then we can use Modifier 50. Definitely Modifier 50
will increase the reimbursement.

6. Modifier 51
 Normally used to unbundle multiple procedure. When multiple procedures are
performed on any patient and we send multiple CPT code through one claim in
that case it’s create confusion. So that’s why to avoid confusion we used
Modifier 51.
 Medicare CMS CCI (correct coding initiative) tool is used for which CPT we can
use Modifier 51.

7. Modifier 52
 Partially reduced or Eliminate services, this modifier is opposite to Modifier 24.
 Modifier 52 is used when provider give less time as compare to usual time
specified for that services.
Example: In- case If provider is performing the procedure and patient was not
being able to tolerate due to any reason that’s why doctor abort the procedure
before completion.
In some cases, Provider may bill twice using modifier 52, if patient come again
to complete the procedure. Then we will bill claim twice and explain the
insurance that you will have to pay partial amount against both claim because
patient come twice and take partial/ reduce services.

8. Modifier 53
 Discontinued procedure
 Modifier 53 is a code used in medical billing when a doctor starts a procedure
but has to stop/ discontinued it early because of unexpected problems. It shows
that the procedure couldn't be finished as planned due to issues like
complications or risks to the patient.
Scenario: A gastroenterologist begins an endoscopy to take a biopsy from a
suspicious lesion, but encounters unexpected bleeding or difficulty in accessing
the target area.
Use of Modifier 53: If the endoscopy is terminated before completion due to
unforeseen circumstances, Modifier 53 can be applied to communicate that the
intended procedure was not fully executed.
9. Modifier 57
 Modifier 57 is normally used with E/M services for decision to perform the
surgery
 Certainly! Modifier 57 is used in medical billing and coding to show that a major
surgery was planned, and a significant decision to perform the surgery was
made either the day before or on the same day as the surgery. Here are
examples in easy wording:
Broken Arm Fix:
 Situation: You break your arm and go to the orthopedic doctor. After looking at
your X-rays, the doctor decides you need surgery to fix the broken bone.
 Use of Modifier 57: If the decision for surgery is made on the same day or the
day before the operation, the doctor adds Modifier 57 to the evaluation and
management (E/M) code for the visit.

Orthopedic Trauma Surgery Decision:

Scenario: A patient is brought to the emergency room with a severe
orthopedic injury. The orthopedic surgeon quickly assesses the situation and
decides that immediate surgery is necessary to address the trauma.
Use of Modifier 57: Added to the E/M service code for the emergency
evaluation when the decision for the orthopedic trauma surgery is made on the
same day.

10.Modifier 58
 Staged or related procedure or service during postoperative period by the same
physician.
 This modifier is usually used with surgeries. It is used when patient surgery is
being performed in different stages, then in that case you will have to repeat
CPT code.
Scenario: if without using modifier 58 we will bill insurance, in that case claim
will be denied due to global period. So avoid global period denial you need to
use 58 modifiers which will indicate that procedure is being performed in stages.
Situation: A patient has cataract surgery in one eye, and the surgeon plans a
follow-up procedure for cataract surgery in the other eye a few weeks later.
 Use of Modifier 58: Modifier 58 is added to the code for the second cataract
surgery to show that it is a planned follow-up

11.Modifier 59
 Indicate that a service or procedure is distinct or independent from other
services performed on the same day.
 Distinct procedure services. This modifier is used in most of claims.
 Usually used to unbundle services. But Medicare does not encourage this
modifier. Medicare suggest to use four other modifiers in place if modifier 59
which will be discussed late.
Scenario-1: A patient receives injections in two different muscles during the
same visit. Without Modifier 59, the system might assume they are part of the
same procedure.
Use of Modifier 59: Adding Modifier 59 to the second injection code tells the
billing system that these are distinct procedures and should be reimbursed
separately.
Scenario-2: A patient has two separate wounds that require repair during the
same office visit. Without Modifier 59, the system might consider it part of a
single wound repair procedure.
Use of Modifier 59: Adding Modifier 59 to the second wound repair code
communicates that these are separate procedures, justifying individual
reimbursement.

12.Modifier 62
 Used for co-surgeons
 If more than one doctors are being involved in a surgery of patient, in that case,
one of the most senior doctor amongst them is called a main surgery doctor,
and all other doctor work as assistant doctors/surgeons. If your doctor is main
surgery doctor in that case, you could not use modifier 62 in your claims. But in-
case if your doctor is working as an assistant surgeon in that case you can use
this modifier.

13.Modifier 76
 Modifier 76 is used to indicate that a repeat or duplicate procedure was
performed during the same day of the initial procedure by the same physician.
 It is important to note that Modifier 76 is specific to repeat procedures on the
same day.
Scenario: A patient with a suspected fracture has X-rays taken of the injured
area. Later in the day, the physician decides to reassess the fracture and orders
a repeat set of X-rays.
Use of Modifier 76: Using Modifier 76 with the second set of X-ray codes
communicates that the physician repeated the procedure for further evaluation
during the same day.

14.Modifier 77
 Modifier 76 is used to indicate that a repeat or duplicate procedure was
performed during the same day of the initial procedure by different physician.
 You may receive a denial like, this claim cannot by paid because the procedure
is repeated on the same day, in that case if procedure is repeated by two
different providers/physicians then we will use modifier 77.

15.Modifier 78
 Return to operating room for related surgery during post-operative period.
Scenario: Appendectomy Complication Patient Case: Sarah undergoes an
appendectomy to remove her inflamed appendix. However, later in the day, she
experiences unexpected bleeding, and the surgeon needs to take her back to
the operating room to address the complication.
Modifier 78 Usage: The medical bill for the second surgery will include Modifier
78 to indicate that the procedure was a follow-up due to unforeseen
complications from the initial surgery.
Scenario: Fractured Bone Setting Patient Case: John breaks his arm, and the
orthopedic surgeon performs a closed reduction to set the fractured bone.
Unfortunately, an X-ray taken afterward reveals that the alignment is not
correct, so the surgeon needs to perform another procedure to adjust the bone.
Modifier 78 Usage: The medical bill for the second procedure will use Modifier
78 to communicate that the repeat procedure was necessary because of
unexpected issues with the initial bone-setting process.
16.Modifier 79
 Unrelated procedure or service by the same physician during postoperative
period.
 it's used when a patient needs another surgery that is not directly related to the
initial one within a certain timeframe.
 Modifier 79 tells insurance companies: "I did another procedure on this patient
during the global period, but it was a completely separate issue. Please pay me
separately for this extra work."
Example:
 John breaks his arm and Dr. Smith sets it (surgery #1). There's a global period
where Dr. Smith would fix any complications with the arm for free.
 Two weeks later, John stumbles and sprains his ankle. This is unrelated to the
arm surgery.
 Dr. Smith treats the ankle sprain (surgery #2) and adds modifier 79 to the bill.
This tells insurance it's a new, separate issue, and Dr. Smith deserves separate
payment.
IMP Note: Remember, modifier 79 is for unrelated procedures during the global
period. If the second procedure is related to the first, it wouldn't need modifier
79.

17.Modifier RT/ LT
These modifiers tell insurance companies: "Hey, I did this procedure twice, once
on each side of the patient's body. Please pay me separately for each side."
Example:
Sarah needs arthroscopic surgery on both knees (separate surgeries, different
days). The surgeon uses "RT" modifier on the bill for the right knee and "LT" for
the left knee. This clarifies that they're two distinct procedures, justifying
separate payment.
CHAP #13 Medicare X Modifier (Replacement of 59)
X series of modifiers was introduced in 2015 by Medicare to avoid/reduce the
abuse of 59. They prevent bundling of distinct services, ensuring providers receive
proper payment for separate work.
Most of the peoples in industry are still using 59 Modifier with Medicare without
analyzing scenario.
If we use proper X modifier in replacement of 59 with Medicare, our claims will be
easily process and reprocess without any appeal. We can although use 59 modifier
for Medicare but X modifiers are more preferable.

 Modifier XE (Separate Encounter)

 X: Stands for "distinct" or "different."
 E: Stands for "encounter," meaning a session with a healthcare professional.
 XE (separate encounter): Used when multiple services are rendered on the same
date of service, but in separate, documented encounters (e.g., two office visits
within one day).
 The key point is that the visits must be considered separate and distinct
encounters even though they occur on the same day. This means they should
address different health concerns or involve different specialists.

 Modifier XP (Separate Practitioner)

 A service that is distinct because it was performed by a different practitioner.
 When multiple doctors of different specialty check the patient.
 If different doctors claim bill, and that is in one encounter but doctors are
different, in this case if claim is denied you can use Modifier XP to unbundle.
Example: A pregnant lady visits the doctor, doctor perform consultation, then
refer to ultrasound specialist, also covid test was performed, in that case we can
use Modifier XP.
 Modifier XS (Separate Structure)
 A Service that is distinct because it was performed on a separate
organ/structure.

 Modifier XU (Unusual Non-Overlapping Service)

CHAP #14 Global Period in US Healthcare
The global period is a period of time during which a physician or other healthcare
provider may not bill separately for certain services related to a surgical procedure.
The global period typically begins on the day of the surgery and ends a specified
number of days after the surgery, depending on the type of procedure.
The global period typically includes the following services:
 The surgical procedure itself
 Preoperative and postoperative care
 Related office visits
 Laboratory tests
 Imaging studies
 Durable medical equipment
The global period typically does not include the following services:
 Services provided by another physician or healthcare provider
 Services that are not related to the surgical procedure
 Services that are provided outside of the global period
Example: A patient has a knee replacement surgery. The global period for knee
replacement surgery is typically 90 days. During this time, the patient's surgeon
may not bill separately for any services related to the surgery, including
preoperative and postoperative care, related office visits, laboratory tests,
imaging studies, and durable medical equipment.
IMP Point:
 Global surgery is not restricted to hospital inpatient setting. It applies in any
setting such as inpatient hospital, outpatient hospital, ambulatory surgical
center and physician office.
 Global period differs by procedure to procedure.
 Usually, it is between 1 to 90 days.
 Pre-Hospitalization and Post-Hospitalization are the part of global period.
Pre-Hospitalization:
 This refers to the period leading up to your surgery.
Examples:
Blood tests and other diagnostic tests.
Post-Hospitalization:
 This refers to the period after your surgery and discharge.
Examples:
Wound care or dressing changes.
Link for checking the global period:
https://www.palmettogba.com/palmetto/global90.nsf/Front?OpenForm#
"This link allows you to check the remaining duration of the global period for a
completed surgery, covering both pre- and post-hospitalization periods."

CHAP #15 How to solve Global Period Denials

Claims are denied for global period when the additional services billed during
global period are included in the main procedure that were performed.
Criteria:
Global procedure for Minor Procedure: 10 days
Global procedure for Major Procedure: 90 days
Step #1: First, determine if the procedure denied is for E&M or another minor or
major surgery. Because modifier will be use on the basis of this information.

1. RESOLUTION ON E&M DENIALS

Case1: Claim denied for E&M code (99201-99215 office visit) with Major surgery
Solution:

 If the E&M code is denied with major surgery, then we can use Modifier 57
which state that decision of surgery was taken during E&M consult before
performing major surgery.
 It state that we were unable to perform this major surgery without E&M
consultation. (Evaluation and management was compulsory).
Case2: Claim denied for E&M code (99201-99215 office visit) with Minor surgery
 If the E&M code is denied with minor surgery, in that case we will use 25
modifiers to show that the procedure performed on the same day was
significant but separately identifiable services. This modifier is mostly used in
medical billing with minor surgeries.
 Usually this denial is received when minor surgery is performed by the provider
and also billed E&M with that minor surgery.
Case3: Claim denied for E&M code during to Post-Operative Period
 If the claim is denied during Post-operative period and the DX code are different
then we use 24 Modifier, which state that unrelated E&M services are
performed.

2. RESOLUTION ON SURGERY DENIALS

Case1: if similar surgery is denied during post-operative period then we can use
Modifier 78 stating unplanned return to the operating room during post-
operative period.
Remember: Modifier 78 is used when an unplanned additional surgery happens
during the global period of a main surgery, using the same surgeon and
addressing a related issue. It doesn't apply to planned second surgeries or
unrelated procedures.
Real Scenario: Breast biopsy
 Main surgery: Breast biopsy (tissue sample removal).
 Post-op results: Malignant cells detected, requiring further surgery.

Case2: If different surgery is denied during post-operative period then we can

use Modifier 79, stating unrelated services by the same physician during post-
operative period. It states the insurance that different surgery is performed in
post-operative global period which is totally unrelated to previous surgery.
Note: if in this case after using 79 modifiers you received denial, then you can
appeal against that denial.
 CHAP #16 How to solve Medical Necessity Denials (C0-50)
Usually Medical necessity denial are considered complex denial in medical billing,
because you must have good knowledge of coding to solve these denials.
Claims is denied for medical necessity when insurance finds that service performed
was not necessary to be performed (LCD/NCD guidelines). When insurance find
that service performed by physician does not match the patient disease. When cpt
code does will not compatible with disease code.
Example: Chest X Ray CPT billed with unrelated body part diagnosis.
Solution: whenever you receive co-50 denials, firstly check if you have any
compatible code in the super bill. Sometime Cpt codes wrong order may also cause
of co-50 denials, because primary cpt code always have high weightage as compare
to other cpt codes.
Resolution
 First Step: Review the medical record to check why the test or procedure is
performed.
 Second Step: verify the diagnosis code with Medicare Coverage Database.
 Link to check: https://www.cms.gov/medicare-coverage-database/new-
search/search.apx
 LCD -> Local coverage determination and NCD is National coverage determination.
 If any insurance deny you claim because of LCD that maybe BCBS, Aetna or any
other in all of these cases you can follow Medicare guidelines. Because all the
insurance companies follow Medicare guidelines.
 Scenario-1: If you billed you claim after following the LCD/NCD Medicare
guidelines, but unfortunately claim is again denied in that case you can print the
Medicare guidelines and attach, and can appeal to insurance.
 Scenario-2: if you didn’t find any compatible cpt code in superbill corresponding
the disease, in that case also you can appeal and justify that the procedure
performed by the provider was necessary for the patient.
CHAP #17 Payment Posting and their Rules
Imagine you go to the doctor for a check-up. After the visit, the doctor's office sends
a bill to your insurance company saying, "Hey, we took care of this person, and
here's what we did."
Now, the insurance company looks at the bill and decides how much they're going
to pay. Let's say your doctor charged $100 for the check-up.
Definition: Payment posting in the medical billing is the process where the received
payments from both insurance companies and patients are accurately recorded
and documented.
Key Steps in Payment Posting:
1. Receiving (EOB) or Electronic Remittance Advice (ERA):
Upon submission of a claim to the insurance company, an EOB or ERA is received.
This document outlines the details of the adjudication process, including the
approved amount, patient responsibility, and insurance payment.
2. Verification of Payments:
The received EOB or ERA is carefully verified to ensure accuracy and to cross-
reference with the billed amount.
3. Allocation of Payments:
4. Adjustments and Write-offs:
Adjustments may be made based on contractual agreements between healthcare
providers and insurance companies.
5. Patient Billing
Once the insurance portion is posted, patient statements are generated reflecting
the remaining balance, if any. These statements are then sent to patients for
payment.
6. Systematic Documentation:
All payment posting activities are systematically documented within the practice
management system. This documentation serves as a detailed record for future
reference, audits, and financial reporting.
Types of Payment
1. Patient credit card, Check and cash deposit
2. Insurance EFT/ERA/EOB payments
3. Insurance check deposit
4. Insurance credit card payments
5. Offset adjustments
6. Reversal / Recoupments

EOB/ ERA Posting

 When claim is process by a payer and find error free, first they apply/issue an
allowable amount to the claim/ line as per their fee schedule.
 Usually we billed double or triple to insurance company in that case insurance
issue payment according to their fee schedule and rest of the amount is called
contractual obligation and applied toward adjustment CO45 (Contractual
Adjustment).
 Patient responsibility is assigned as per their plan. Deductible (PR1),
Coinsurance(PR2), Copay (PR3).
 For example, if we billed 100$ to insurance and insurance allowable amount is
70$, in that case remaining 30$ will be called adjustment, and if the patient has
20$ deductible and 20$ copay, in that case deductible and copay amount will
also detect by insurance company from allowed amount (70$) and in that case
paid amount will be 30$.
CHAP #18 How to solve Hospice Denials (COB9)
Patient who have terminal illness and a life expectancy of six months and less
enrolled in Hospice Care and admit in hospital.
IMP NOTE:
 Usually we receive Hospice denials through Medicare Part B.
 Hospice Care is coverage given under patient Part-A Medicare Coverage in
Hospitals.
 When a patient is enrolled in Hospice care under a hospital, physician’s claims
are start getting denied.

How to Solve Hospice Denials?

 Before solving these claims, you must know that for which disease patient is
admitted in hospital hospice care. Once if you came to know the disease for
which patient is admitted in that case you can easily solve this claim. These
denials are also solved using Modifier.
 If the services are performed unrelated to Hospice disease, we can use GW
Modifier. This modifier states that the service performed are unrelated to
Hospice disease.
 You 90% Hospice claims are solved with GW Modifier.
 If the services performed are related to Hospice disease but the physician is not
employed by the hospice care or Hospital and providing service as a private
physician, then we can use GV Modifier.

What is Hospice?
Hospice is a special kind of care for people who are very sick and may not get better.
It focuses on making them as comfortable as possible, providing support not just
for the sick person but for their family too. The goal is to give the best quality of life
in their last stages

CHAP #19 Parts of Medicare (A, B, C, D)

What is Medicare Insurance?

 Medicare is federal (government) Health insurance program.
Eligibility:
 US citizens People who are 65 years or old
 Certain young people with certain disability
 People with ESRD (End stage Renal Disease) like permanent kidney failure.
 This is the most common and affordable insurance in US that does not require
any Preauthorization and Referral.
 This is like commercial insurance.
Different Parts of Medicare
 Part A
This part covers hospital admission, skilled Nursing, Hospice care etc. claims are
send by Hospital.
 Part B
This Part covers outpatient Services including physician’s professional services.
When patient does not need to admit in hospital for more than 24 hours. This
part cover provider expenses and claims are send to insurance through provider
name.
 Part C (A+B+D)
Medicare Funded alternative insurance coverage called Medicare Advantage
plan that a patient can choose. This Advantage plan include Part A, B and D
benefits. It lets you get all your Part A and Part B benefits through a private
insurance plan instead of traditional Medicare.
 Part D
This part help to provide Prescription Drug coverage. It means if patient take
medicines form provider or medical stores he will not have to pay for those
medicines if patient have Medicare part D.

CHAP #20 New & Established Patient Rules

It’s important to know whether the patient is new or established patient because
different cpt codes are used for new and established patient.
New Patient: A patient who is receiving professional services from the provider for
the first time or after a gap of 3 years will be called a new patient.
Established Patient: Established patient is one who has received professional
services from the provider in the last 3 years. Whose last visit gap is not more than
3 years.
 Important Points
 If patient is seen in the same group and same specialty doctor, then the patient
will be considered as Established patient.
 If a patient is seen in the same group but different specialty doctor, then for
the doctor the patient will be considered as New patient.

CHAP#21- New & Established Patient Billing Codes

New Patient Codes:
1. CPT Code 99202
 Straight forward Medical decision making(MDM),
 Consultation Time: 15-29 minutes.
 Description: Office or other outpatient visit for the evaluation and management
of a new patient, which requires a medically appropriate history, examination,
and straightforward medical decision-making.
 IMP Note: 99201 was also used as E&M code, but it’s deleted from 2020.
2. CPT Code 99203
 Low level Decision making(MDM)
 Consultation Time: 30-44 minutes
3. CPT Code 99204
 Moderate Level MDM
 Consultation Time: 45-59 minutes
4. CPT Code 99205
 High Level MDM
 Consultation Time: 60-74 minutes

Established Patient Codes:

1. CPT Code 99211
 Office or Other Outpatient Visit.
 This Cpt code is used when patient has minimal problem and physician does not
need to check the patient
 It's typically a brief encounter that may involve minimal face-to-face time with
the provider.
Example: Imagine you go to your doctor's office for a flu shot. The nurse, who is
qualified to use CPT Code 99211. CPT Code 99211 is often used for straightforward
services like vaccinations, blood pressure checks, or quick consultations.
2. CPT Code 99212
 Straight forward MDM
 Consultation time: 10-19 Minutes
3. CPT Code 99213
 Low Level MDM
 Consultation Time: 20-29 Minutes
4. CPT Code 99214
 Moderate Level Decision Making
 Consultation Time: 30-39 Minutes
5. CPT Code 99215
 High level MDM
 Consultation Time: 40- 54 Minutes

Prolonged Service Codes:

1. CPT Code 99415
2. CPT Code 99416

CHAP #22 Annual Wellness / Preventive Care Billing Rules

What is Preventive Care?

Imagine you're taking care of your car. You get regular oil changes and tire rotations
to prevent problems down the road. Annual wellness visits and preventive care are
similar! They aim to catch health concerns early and keep you healthy, saving you
trouble and money later.
Annual wellness visit: This is your yearly checkup with your doctor, like a big
inspection for your body. They'll talk to you about your health, family history, and
lifestyle, do some basic checks (like blood pressure), and update your
immunizations. It's a chance to discuss any concerns you may have and plan for
future care.
Preventive care: These are specific services recommended based on your age,
health, and risk factors. Preventive care helps to detect or prevent serious diseases
and medical problems before they can become major.
IMP POINT: it is usually performed by PCP once in calendar year. And most health
plans are required by law to cover these services at 100%.

Preventive Care CPT Codes for Commercial Insurances

CPT Codes for New Patient

If patient is taking preventive care for the first time, in that case he will be consider
a new patient.
1. 99381 [For Younger than one year]
2. 99382 [1 – 4 years]
3. 99283 [5 – 11 years]
4. 99384 [12 – 17 years]
5. 99385 [18 – 39 years]
6. 99386 [40 – 64 years]
7. 99387 [65 years and older]

CPT Codes for Established Patient

1. 99391 [For Younger than one year]
2. 99392 [1 – 4 years]
3. 99293 [5 – 11 years]
4. 99394 [12 – 17 years]
5. 99395 [18 – 39 years]
6. 99396 [40 – 64 years]
7. 99397 [65 years and older]
Primary DX code will always be: Z00.00 - Description - Encounter for general
Examination without abnormal finding. You can use another diseases code after
this, but make sure that the primary code is Z00.00.

CHAP #23 Medicare Preventive Care Billing

We can’t use CPT codes for Medicare manage care / advantage plan, we will use
HCPCS codes:
 Go438 - Annual wellness visit includes a personalized prevention plan of
service, initial visit. (You Cannot bill this cpt if patient has not completed 12
months with Medicare)
 Go439 - Annual wellness visit includes a personalized prevention plan of
service, Subsequent visit.
 Go402 - Initial Preventive physical examination: Face-to-face visit with new
Medicare Beneficiary during the first 12 month of Medicare enrollment.

CHAP #24 Claim Correction & Resubmission Codes

Why claim is corrected?

 When a claim is denied by the payer for any reason and some corrections are
necessary, then we send a corrected claim to the payer with changes needed. A
corrected claim is replacement of a previously submitted claim.
 Corrected claim is always reported with the original reference/claim number
so that the insurance company can compare the changes.
 Resubmission code is sent on the claim form Box 22 to report these claims. and
the resubmission code will be 7 in 22 box.
 Resubmission code is not necessary in Medicare.

Resubmission Codes
1. Resubmission Code 1
It is normally used for new claims which is being billed for the first time.
2. Resubmission Code 7
It is normally used for replacement claim of a previously submitted claims which is
denied.
3. Resubmission Code 8
It is normally used to void a claim which was billed in error or mistake.

CHAP #25 What is Capitation in US Healthcare

What is capitation Agreement?

 Capitation agreement is a contract between insurance companies and Health
Care Provider. Under this contract, Physician agrees to receive a predefined fix
amount every month/year from the insurance. Insurances companies Prefer to
pay according this agreement rather than processing one-by-one claims.
 Claims for these insurances/ patients are processed with zero allowable.
 The reason code assigned for these Capitated claim is CO-24 - and chargers are
covered under a capitation agreement.
Example: physician having 200 patients with Aetna HMO will get lumpsum amount
of $20,000 if per patient price is fixed as $100.
Benefits:
 Patient having Capitated insurance can get treatment from the Doctor Several
times without Paying anything.
 For the Provider point of view, they will get paid for each patient even if the
patient is seen in that month.
 CHAP #26 HCPCS Codes and Their Use

 The HealthCare Common Procedure Coding System is called HCPCS. HCPCS is a

Standardized coding system that is used primarily to identify products, supplies
and services not included in the CPT codes.
 These Services are including Durable Medical Equipment (DME), Prosthetics,
Injections, supplies etc.
 These services can be non-physician based like Wheelchair, Ambulance
services, walkers etc.
Identification:
These codes can be identified easily because these are alphanumeric 5- digit codes.
First digit is Alpha and all other digits are number.
Example: A0100 (Emergency Taxi), G0008(Flu Vaccine Admin), H001(Alcohol
Screening), j3420(Vit B12 ---injection code-----all injections code are usually start
from J), K0001(Wheelchair), U0001 (Covid RT-PCR Test----Corona Codes).

CHAP #27 What is HIPAA in US Healthcare

 HIPPA is the Health Insurance Portability & Accountability Act of 1996.

 HIPPA act of 1996 is a federal law that required the creation on national standards
to protect sensitive Patient Health information (PHI) from being disclosed
without the patient consent or knowledge.
 All the entities like Healthcare Providers, Healthcare Plans, Clearing Houses &
Business Houses and Business associates are strictly bound to follow HIPAA rules.
IMP POINT: US Department of Health & Human Services (HHS) issued the HIPAA
privacy rules to implement the requirements of HIPAA.
PHI includes but is not limited to the following:
Patient Name, Address, Birthdate, Social Security Number, Medical History, Any
Mental/Physician Condition. Each Employee is trained on policies and procedure
on HIPAA before getting login. HIPAA violations could lead to Practice penalties and
even prison in some cases.
CHAP #28 Medicare Advantage or Managed Care Plans

 Medicare Advantage is a type of Health Insurance Plan that provides Medicare

Benefits through a private Insurer.
 All the peoples whose are eligible for Medicare and they want to take a private
insurance with some additional benefits that is called Medicare Advantage Plan.
 In a Medicare Advantage Plan, a Medicare beneficiary pay the Medicare
monthly premium to the federal government but received coverage via
private insurance company.

Q# Why People choose Private insurance with Medicare?

 These insurance companies offer various type of coverage to the patients
including “Inpatient Hospital Part-A”, “Outpatient Part B” and sometimes also
“Prescription Drug Coverage Part D” as well.

What are Medicare Advantage Plans?

 Most of the PPO & HMO plans are “Managed Care” Medicare Advantage Plans.
 Manage care means a Medicare plan is being managed by a private insurance
companies. In fact, Manage Care and Medicare advantage Plan Both terms are
same.
 These Manage Care/ Medicare Advantages Plans are also called Medicare Part
C Plans.
 All the Manage Care/ Medicare Advantages Plans are strictly bound to follow
the Medicare rules/ guidelines.
IMP NOTE: Private companies receive a fix amount each month for each patient
from Medicare to cover these patients.

Medicare Advantage Plans Denials

Whenever you see a Denials code C0109 from Medicare Stating, “Coverage is
covered by another payer”, it is certain that patient has moved to advantage Plan.
Solution: You just need to find the exact name of the insurance through Medicare
portal and confirm the correct ID to file the claim to the new payer.
 CHAP #29 Place of Service (POS) Codes

 Place of service is the location/facility where the services are performed or given
by Provider or Health Care Professional. It is necessary to mention place of
service on Professional claim form, without it claims cannot be released.
 CMS has designated a complete code of list of the place of Service which is
standard across US Healthcare process.
Commonly used POS are following:
 Pharmacy (01)
 Telemed (02) ---- Consultant without face-to-face meeting
 School (03)
 Prison/Jail (09)
 Office (11)
 Home (12)
 Inpatient Hospital (21) ---- If patient stay for more than 24 hours, he
considered Inpatient
 Outpatient (22)
 Emergency Room Hospital (23)
 Skilled Nursing facility (31)
 Hospice (34)

CHAP #30 What is Crossover Claim

 Definition: A crossover claim in medical billing occurs when a healthcare provider

submits a claim to the primary insurance, and any unpaid portion or remaining
balance is automatically forwarded to the secondary insurance for additional
coverage. This process helps maximize reimbursement and reduce out-of-pocket
costs for the patient.
 It refers to a situation where a patient has coverage under more than one
insurance plan. This typically happens when a patient is covered by both
Medicare and a secondary insurance, such as Medicaid or a private insurance
plan.
 During payment posting, we often see that claim is crossover to another
insurance.
 This usually happen with State Medicare insurance ERA.
 When Medicare process the primary Claim and directly forward their information
to the secondary payer, a Crossover Claim is created.
 Real-life Example: John has both a primary insurance plan from his employer and a
secondary plan from his spouse's work. He breaks his arm and receives treatment at
the hospital. The hospital first submits a claim to John's primary plan, which pays
80% of the cost. The remaining 20% is then submitted as a crossover claim to John's
spouse's plan, which covers the remaining portion.
IMP NOTE: it is not necessary to send claim through provider billing software to
secondary insurance when crossover claim is processed.
 A Coordination of Benefits Contractor (COBC) is used to electronically/
automatically cross over claims billed to secondary payer.
How we will be identified that the claim is crossover? Let’s check this picture.
CHAP #31 Understand Medicare Secondary Payer (MSP)

Medicare Secondary Payer (MSP) is the term generally used when the Medicare
program does not have primary payment responsibility.
Imagine you're moving to a new place, and you have two friends offering to help
you with your furniture. Your first friend helps you move the big sofa, and your
second friend assists with carrying the chairs. If the second friend notices that the
first friend missed a chair, they'll step in and help, making sure everything is moved
successfully. Similarly, Medicare is like the second friend, stepping in to help if your
primary insurance plan doesn't cover all your medical expenses.
Real-Life Example:
Let's say you're a retiree, and you have both Medicare and a retiree health plan
from your former employer. If you need medical care, your retiree health plan
would be the primary payer, covering as much as it can. If there's anything left to
be paid, Medicare steps in as the secondary payer to help cover the remaining
costs. It's like having a backup to make sure your medical bills are taken care of.
IMP POINT: This scenario happens usually when another entity has the
responsibility for paying before Medicare.
These are different scenario where MSP will be applicable (Medicare will become
secondary Payer)
 Working aged Beneficiary: when someone is still working or their spouse is, and
they have health insurance through their job (EGHP employee group health
Plan), Medicare becomes the secondary payer. It means Medicare helps cover
medical costs after the primary insurance plan (like the work insurance) has paid
its part.
 End stage Renal Disease Beneficiary: If patient has end stage renal disease in
that case he will be definitely eligible for Medicare. But if he has also another
insurance then Medicare will become MSP in that case.
 Disabled patient under LGHP: Employee with disability gets primary coverage
through their employer insurance first and similarly Medicare will become
Secondary payer.
 No Fault insurance, including Auto: The treatment caused by an auto accident
should be covered by the Auto Insurance first before Medicare.
 Worker Compensation (WC) Before Medicare: Treatment related to injury/ sick
during job will remain first responsibility for Worker Compensation (WC).
[Links for details are in video description]
CHAP #32 How to Solve CO-22 Denials

 CO-22 or PR-22 is the most common denials mostly comes from Medicare.
 CO means Contractual Obligation and PR means Patient Responsibility.
PR-22: This denial code states that payment adjusted because this care may be
covered by another payer per coordination of benefits. (Means Medicare says that
another payer should pay first).
Important: These denials come when we file a Primary claim to Medicare and
Medicare states that they are secondary after another Insurance. The reason for
this denial is either COB or MSP.

How to solve CO -22 Denials?

Below reason codes could be present along with CO -22 or PR -22 to show MSP
Class:
MSP Type Secondary coverage Reason
Type 12 If the patient is an aged worker or spouse with an employer
group health plan of more than 20 employees
Type 13 Covered under End stage renal disease coordination period,
which is typically first 30 month
Type 14 or 47 Covered under a no-fault plan, which usually includes any
liability or auto claims
Type 15 Covered under worker compensation claims
Type 42 Covered under a veteran administration plan
Type 43 Is disabled and the employer’s group plan has 100 or more
employees

 To confirm who is the primary payer, we will go to the Medicare portal and put
patient information.
CHAP #33 What is COBRA in US Healthcare

 COBRA is an acronym of consolidated Omnibus Budget Reconciliation Act 1985.

 Large employers in the U.S, those with 50 or more full-time workers, are
required to provide health insurance to their qualifying employees.
 If an employee become ineligible to receive an employer’s health insurance
benefits, the employer may stop paying its share of the employee’s insurance
premiums.
 COBRA allows an employee and their dependents to retain the same insurance
coverage for a limited period of time after leaving the job, incase if patient is
willing to pay premium on their own.
 COBRA health insurance program only cover cost of health insurance related
services. It does not include life insurance and disability insurance.

[Links for details are in video description]

CHAP #34 How to Solve Medicare CO-109 Denials

We often receive denials from Medicare with reason code CO-109.

Description of this denial:
Claim/Service not covered by this payer. You must send the claim/ service to
correct payer. In this case you will be need to find that patient has which another
insurance and then the claim will be send to that insurance.
IMP NOTE: Medicare usually pay claims through EFT rather than Cheque. So in this
case we usually receive ERA.
This denial states that patient has move to an advantage/ Managed care insurance
from traditional Medicare.

How to solve CO-109

 You need to go to your Medicare Portal and submit patient’s basic information.
 When you will search on Medicare portal by filling the all necessary information,
in that case on next screen, you will find multiple tabs and you will have to
choose Plan Coverage tab to check the patient plans.

 This information is not enough we must have also a patient Member id,
sometime we find member id easily on Medicare portal, but if we didn’t find
then we need to go on a portal of that insurance let se Well-care to find the
member id.
 You may or may not get exact subscriber ID for the advantage plan, but you can
confirm that with various methods. (like website portal or call to insurance etc.)
 Then simply we will update the information in patient demographic.
 In this case we will send fresh /new claim to Well-care, we cannot submit
corrected claim to well-care.

CHAP #35 What is COB (Coordination of Benefits in Us Healthcare)

 Sometime two or more insurance plans work together to pay claims for the
same person. That process is called Coordination of Benefits.
 in most of the cases maximum payment will be done by insurance, if patient
have only one insurance then it will be very easy that we will directly send claim
to that insurance.
 But in-case when patient will have multiple insurance in that case first we will
be need to determine that which insurance is primary and which insurance is
secondary before submitting the claim. If you will submit claim directly to
secondary insurance without verifying in that case, you maybe receive CO-22
denial.
 Insurance companies use COB to confirm which plan will pay first, to avoid
duplicate payment, and it also help to reduce the cost of insurance companies.

How insurance company determine which insurance is primary or secondary?

 The Benefits Coordination & Recovery Center (BCRC) is used to verify COB
between different insurances.
 BCRC help insurance to avoid unnecessary claim/incorrectly submit claim, and
also help to reduce insurance cost.

COB Examples
Example-1: When patient has both health & Auto insurance and the coverage will
be depending on disease. In this case if patient has fever and we submit claim to
auto insurance in that case definitely claim will be denied.
Example-2: when patient has two insurances and to determine which one is
primary & Secondary.
Example-3: when patient has insurance from employer and self both.
CHAP #36 How to solve Coverage related Denials (PR-26, PR,27)

 When we file a claim to insurance, but the insurance is not active on that date
of service then we get a denial for coverage.
 This is most common denial in medical billing, because patient policy may be
active or inactive on a specific date of service.
 These denials can be solved by talking to the patients or little research in our
system or correspondence with the patient.
 In case if billing company unable to contact patient, then claim will be billed to
insurance.

Usually 2 types of denial codes insurances issue:

 PR-26 (Expenses/charge incurred prior/before starting the coverage)
This denial occurs when claim is filed before starting the coverage/policy.
Example: if claim is filed for DOS 15 March 2022 but coverage is starts from 16
March 2022.
 PR-27 (Expenses incurred after coverage terminated)
Example: if claim is filed for DOS 20 March 2022 but the coverage is already
terminated on 1st March 2022.
IMP: In both cases claim will be billed to patient. And you will contact to
patient.
CHAP #37 ICD-10 chapters and their Code Ranges

ICD-10 (International Classification of Diseases) 10th Edition, is a system used in

medical billing to code various diseases, conditions, and procedures. It's like a
universal language that healthcare providers and insurers use to communicate
about a patient's health. These are also known as disease code or DX code.
Format: ICD-10 code format consists of alphanumeric characters which typically
consist of 3-7 characters.
ICD-10 code ranges typically covered in 21 chapters, it means that 21 types/ kind
of diseases will be discussed:
Chapter Code Range Description
1 A00- B99 Certain infectious and Parasitic Diseases
2 COO-D49 Neoplasm (cancer diseases)
3 D50-D89 Diseases of the blood and blood-forming organs and
certain Disorders involving the immune mechanism
4 E00-E89 Endocrine, Nutritional and Metabolic diseases
(diabetes, all related to immune system)
5 F01-F99 Mental, Behavioral and Neurodevelopment-Disorder
6 G00-G99 Diseases of Nervous system (Brain related)
7 H00-H59 Diseases of Eye and Adnexa
8 H60-H95 Diseases of Ear and Mastoid Process
9 I00-I99 Diseases of Circulatory System (Blood circulatory
system, Heart Related)
10 J00-J99 Diseases of Respiratory System ("Diseases related to
breathing or the lungs."
11 K00-K95 Diseases of Digestive System
12 L00-L99 Diseases of Skin and Subcutaneous
13 M00-M99 Diseases of Musculoskeletal System and Connective
Tissue (Muscle related like bones etc.)
14 N00-N99 Diseases of Genitourinary System
15 O00-O9A Pregnancy, Childbirth and Puerperium
16 P00-P96 Certain conditions Originating in the Perinatal Period
(Perinatal Period means when child birth)
Chapter Code Range Description
17 Q00-Q99 Congenital Malformations, Deformations and
Chromosomal Abnormalities
18 R00-R99 Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings (like Blood testing diseases,
symptoms)
19 S00-T88 Injury, Poisoning and certain other Consequences of
External Causes
20 V00-Y99 External Causes of Morbidity ( These are not disease
codes) used to describe any situation and normally
avoid to use as a primary code
21 Z00-Z99 Factors influencing Health Status and contact usually
avoid to use as a primary code

CHAP #38 In Network & Out of Network Provider Rules

 "Network" refers to the group of doctors, hospitals, and other healthcare

providers that have agreed to work with the insurance company to provide
services at discounted rates. There are two main types of providers based on
their relationship with your insurance plan: "In-Network" and "Out-of-
Network."
In-Network Providers:
 Definition: These are healthcare providers who have a contract with your
insurance company.
Out-of-Network Providers:
 Definition: These are healthcare providers who do not have a contract with your
insurance company. It means that the provider is not in the patient insurances
list.
 Before getting paid by insurances, every doctor/provider/Group need to
enrolled themselves with the insurance companies.
 This whole process is called Provider/ Participation/ Credentialing.
 Payment will not issue without participation with insurance.
 And out of network deductibles will be applied in this case to patient.
CHAP #39 CPT/Procedure Codes Ranges with their Specialty

CPT codes are 5 digits’ numeric codes. CPT code is also known as Procedure code
or treatment code.
1. 99202 – 99499: Evaluation & Management (Consultation codes)
2. 00100 – 01999: Anesthesia (Anesthesia is a medical process used to make a
person unconscious or numb to prevent them from feeling pain during
surgery. It's like a temporary state of controlled sleep or numbness. It is mostly
used for surgical procedures).
3. 10004 – 19499: Integumentary System (skin related procedure)
4. 20100 – 29999: Musculoskeletal System
5. 30000 – 32999: Respiratory System (human body responsible for breathing)
6. 33016 – 37799: Cardiovascular System (Heart and pumping procedures)
7. 38100 – 39599: Hemic & Lymphatic Systems:
Hemic System deals with blood production and its components, while the
Lymphatic System manages fluid balance, filters harmful substances, and supports
the immune system.
8. 40490 – 49999: Digestive System
9. 50010 – 53899: Urinary System
10. 54000 – 55980: Male Genital System
11. 56404 – 58999: Female Genital System
12. 59000 – 59899: Maternity Care & Delivery
13. 60000 – 60699: Endocrine System
14. 61000 – 64999: Nervous System
15. 65091 – 68899: Eye & Ocular Adnexa
16. 69100 – 69979: Auditory System (Ear related procedures)
17. 70010 – 79999: Radiology (ultrasound, X-ray)
18. 80047 – 89398: Pathology & Laboratory (Lab Test related)
19. 90281 – 90999: Medicine, Vaccine, Toxoids, Psychiatry, Dialysis
20. 91010 – 93998: Gastroenterology, Ophthalmology, Cardiovascular (involve
Testing)
21. 94002 – 99607: Pulmonary, Allergy, Endocrinology, Neurology, Behavioral,
Chemotherapy
CHAP #40 What is Clearing House in US Healthcare

 A Healthcare Clearing House is the middleman between the healthcare

providers billing system and the insurance payers.
 The Clearing House looks for any mistakes or missing information in the bill. If
there are any issues, and ensuring the claims can get correctly processed by the
payer.
 Once everything is in order, the Clearing House sends the bill to your insurance
company.

Billing Software - CLEARING HOUSE - Insurance software

 Clearing House transcribe non-standard data into standard data formats like
835 / 837 data files that can be transfer electronically into payer’s adjudication
system.
Clearing House Functions
 Along with claims, Clearing House also exchange electronic payment
information through ERA.
 Clearing House also provides electronic Eligibility Verification which saves lots
of manual effort.
 It has lots of compliance and claims editing tools that helps providers and Billers
to release clean claims to payers like NCCI, NCD, LCD, latest ICD and CPT
modules etc.
 The major Clearing Houses are RelayHealth, Capario, Trizetto, change Health,
Waystar etc.

CHAP #41 How to Solve CO-18 Duplicate Claim Denials

 When a claim is filed/ received by the insurance more than once then insurance
company deny the claim for duplicate. This is the most frequent denial in the AR
process.
 This denial code issued for duplicate claim is CO-18.
 There could be several reasons behind this denial which can be corrected by
looking at the actual reason.
 Solution to the Duplicate Claims
Scenari-1: when same claim or service submitted to the insurance company more
than once, but the service performed only once.
Solution: Confirm the original claim Status
Scenario-2: if same service performed more than once by the same provider.
Solution: Modifier will be used to differentiate same services.
Scenario-3: if claim has been corrected but it’s been resubmitted without indicating
as corrected claim. (with resubmission/ corrected code 7)
Solution: The Claim need to be sent with resubmission code 7 and original claim
number to get processed correctly.
Scenario-4: if claim billed twice but originally performed only once. (biller mistake)
Solution: Confirm with billing team and void/adjust accordingly. Claim will not pay
by insurance in this case.
Scenario-3:

CHAP #42 How to work on Timely Filing Denials (CO-29)

 Insurance companies set a deadline or time limit for doctors to send in these
bills. This is known as the "timely filing limit."
 If the doctor doesn't send the bill within the set time limit, the insurance
company can deny or refuse to pay for that service. This denial is called a "timely
filing denial."
 If the insurance company does not receive a claim within a specific TFL, the claim
gets denied for TFL, and denial code CO-29.
 The time limit could be either 30 to 365 days or one-year depending on the
insurance.
 The time limit starts from the date of service not from the day you billed claim.
 Insurance companies calculate TFL from the day of date of service to the day
they receive claim on their files.
Example: you billed a claim for DOS 1st January on 10th January to UHC so the
insurance company should receive the claim 1st April.
The reasons could be:
 Incorrect information
 Misrouted claims (mistakenly send incorrect payer)
 Typo Error
 EDI rejection
EDI is done by clearing house. So If claim has any mistake like we billed claim we
incorrect DX code in that case claim will be rejected by clearing house. In that
case claim will not be received by payer.
 Wrong payer Id
 Wrong mailing address
How to work on TFL Claim
 It is necessary to work on EDI rejections in timely manner to prevent these
denials.
 No response Aging claims should be worked in a timely fashion.
 If you still receive a CO-29 TFL denial, verify EDI report and use it as Proof of
Timely Filling and appeal.
 If claim is filed on paper, use the postage proof as proof of TFL and appeal.
CHAP #43 What is CLIA & Its Importance in US Healthcare

 This is the most important topic for laboratory billing. CLIA stand for Clinical
laboratory improvement amendments Act 1988. It's like a Quality Control
System for Medical Labs.
 It regulates laboratory testing and require clinical laboratories to be certified by
the center for Medicare & Medicaid Service (CMS).
 Lab must have CLIA certificate to perform any patient test.
 CLIA sets rules for labs to follow. Labs must comply with these rules to ensure
they're producing accurate and reliable results.
 CLIA is very important as the accuracy of clinical laboratory tests results can be
a life or death matter for patient.
Example: if glucose tests are not performed correctly, a patient could receive an
incorrect insulin dosage.
Three federal agencies are responsible for CLIA:
1. FDA – The food and drug administration
2. CMS – Center of Medicare and Medicaid Services
3. CDC - The center for Disease Control & Prevention
IMP NOTE: Some of the tests are considered so simple and less risky so CDC & FDA
consider them CLIA Waived and can be billed without CLIA certificate by adding
modifier QW.
Please follow video Description to find these CLIA Waived tests.

CHAP #44 Difference Between Denials & Rejections

Rejections Denials
Claim usually rejected by clearing Usually we received denials from
House insurance

Usually comes for data error like invalid Usually receive because of any contract
DX, special character, or invalid claim violation like coverage, necessity,
format duplicate etc.

Can be found on clearing House sit or Can be found on payer ERA & EOBs
Claim Scrubber

Correction can be done without Claim must be sent as a corrected claim

marking as corrected claim

Timely filing limit does not began Timely filing limit begin start since the
because payer still not receive the claim claim is received by the payer for
processing

Most common Rejections and Denials

Rejection:
 Inaccurate patient information
 Diagnosis code is invalid
 Sent to incorrect payer id
 Primary claim balance not match
 Invalid policy number
Denials
 Duplicate claims
 Referral/ authorization is missing
 Sent to incorrect payer
 Coverage terminated

CHAP #45 What is Medicaid Spend Down

 A person with Medicare whose income is too high to qualify for Medicaid might
still be able to get Medicaid.
 Imagine there's a rule in a specific state saying that if your salary is below $5000,
you can get Medicaid. If it's more than $5000, you don't qualify.
 Now, let's say someone has Medicare, their salary is higher than $5000, but they
have really high medical expenses. In this case, we can subtract those medical
expenses from their salary. If, after subtracting, their income falls below the
$5000 limit, they can become eligible for Medicaid through a program known
as "Medicaid spenddown."
 If their expenses toward their medical bills and insurance premiums are reduced
from their total income and they meet the Medicaid threshold, then these
people are also getting qualified for Medicaid.
 And this kind of Medicaid coverage arrangement is called Medicaid Spend
down.
Example:
Medicaid Threshold - $5000
Income - $6000
Medicare Premium - $200
Income - Medical Expenses = Eligibility
$6000 – 200 – 1000 = $4800
These arrangements are not permanent and usually last up to 6 months.
Not Everyone get spend down, under the following condition anyone will be
Eligible
 Child under 21 years of age
 Adult over 65 years
 Disabled or blind
 Families with one or both parents absent, dead, disabled or out of work.
Detailed document link is in description

CHAP #46 What is Overpayment, Offset Adjustment, Reversal & Refund

What is Overpayment?
 Overpayment in medical billing happens when a healthcare provider receives
more money than they are entitled to for a particular service or procedure.
 If an insurance company make a payment to provider in error or because of
billing error, the issued payment is called overpayment.
Possible Reasons could be:
 Incorrect billing
 Insufficient Documentation
In some cases, insurance already process the claim and then demand for
additional documents, in that case we will not provide document then in that
case insurance will demand to return back. That is also consider as
overpayment.
 Medical Necessity errors
 Processing errors by insurance
 Coordination of Benefits issues
What is offset Adjustment & Reversal
 To Recover the overpayment amounts, insurances often send reversals in the
future claims where they reverse the amount from the overpaid claim and apply
it to a newer claim where payment is due.
 An offset adjustment occurs when there is a correction made to an
overpayment or an incorrect payment by deducting or offsetting the amount
from a future payment.
 They show these adjustments in their EOB or ERA.
 This process of adjusting the old payment and applying it to new claim is called
offset Adjustment.
 Example: Imagine a situation where a healthcare provider receives a payment
of $200 for a service, but it was supposed to be only $150. Instead of asking for
a refund, the provider may choose to offset the extra $50 from the next
payment they receive for a different service.
What is Refund?
 Sometime insurance companies do not adjust claim by offset or these is no
future claims, they ask providers to send the overpayment money back. In this
scenario, they issue refund request to provider.

CHAP #47 Difference between Professional & Institutional Claims

PROFESSIONAL BILLING INSTITUITIONAL BILLING

Used for Medical Professionals like Used for Medical Care Institutes like
Doctors, Nurses etc. Hospitals, Nursing Homes etc.
CMS1500 (paper) or 837p (electronic) UB04(paper) for paper and
format is used for professional claims. 837i(electronic) used for institutional
claims
Responsible for billing of services Responsible for billing of facilities
rendered by the Health care providers provided by the institutions.
Mostly called Physician Billing Mostly called Hospital Billing
Billed for professional services like Billed for supplies like medical
medical consolation, physiotherapy etc. equipment, supplies, labs, radiology.
Billing amount and reimbursement is Billing amount and reimbursement is
usually moderate usually high
Covers under Medicare Part B Covers under Medicare Part A

CHAP #48 Medicaid denial Primary Paid more than Allowed – (OA23)

 While working on AR claims, we often get lots of Medicaid secondary claims

denials. The reason for this denial is usually 23 along with 45 (0A23 & CO45).
 This usually happen when there is already a primary payer which has processed
the claim and paid their part and some amount is left as Co-insurance for the
secondary payer.
 And in this case of this denial Medicaid will be secondary payer.
 When the secondary claim is filed to the next payer, the primary claim
processing information is also sent via COB information.
 Under the COB information, if primary payer’s payment is more than Medicaid’s
allowable amount then Medicaid won’t pay.
 Stating primary has already paid more than their allowable amount already.
Example is below:

 AS it is shown in above picture that primary payer pays $71.36 which is the 80
% of allowable amount. And claim will be processed by Medicaid in that case
the allowable amount for cpt code 99213 is $65.50, but primary payer already
pays more than allowed amount of Medicaid, so that’s why now Medicaid will
not pay this claim.
 Usually we won’t be able to pay this claim by Medicaid and we have to write off
this claim.

CHAP #49 What is EHR/EMR System

 In the old era, Doctors were using pen papers to note down all the medical
documentations.
 The full meaning of EHR is electronic health record system.
 EMR stand for Electronic medical record. But EHR and EMR are same.
 EHR is a digital version of a patient’s paper chart used to store all electronic data
in one system.
 EHR are real-time (internet system is req.), patient-centered records that make
information available instantly and securely to the authorized user.
 EHR contains patient’s medical history, diagnoses, medications, treatment
plans, allergies, radiology images, laboratory and test results.

What is PM System?
 Practice Management software refers to a type of software system that helps
healthcare and medical practices streamline their operations. We have many
PM systems available in market which offers both Web & Window based
interfaces.
 Like eclincalwork and advanceMD etc.

CHAP #50 Difference Between CLIA and CLIA waived Testing

What is CLIA?
 The Clinical Laboratory Improvement Amendments of 1988 (CLIA) are
regulatory standards that apply to all clinical laboratories in US.
 CLIA program sets standards and issues certificates for clinical laboratory
testing.
 The objective of CLIA is to ensure the accuracy, reliability and timeliness of test
results.
 Upon Certification, a ten-digit alphanumeric number is assigned to the
laboratory site.
 CLIA number filled in block 23 of CMS 1500 form.

What is CLIA waved Test? (No need of CLIA Certification)

 They are certain laboratory tests which are determined as so simple or there is
very less risk of error.
 Some testing methods for glucose and cholesterol, pregnancy tests along with
some urine testing etc.
 If the payer denies any of these test stating the CLIA ID is missing, we can
resubmit the claims by adding QW which states the performed test is CLIA
waived.
 QW modifier states that this test comes under a CLIA Waived program.

Link in description for all cpt which support QW modifier

CHAP #51 What is NPI in US Healthcare

 NPI is a 10-digit unique numeric identifier for Healthcare Providers & Groups.
 NPI were introduced in 1996 under HIPPA act to improve the efficiency of
electronic health records.
 NPI is used to acknowledge Providers and groups by all the Medicare, Medicaid
and commercial payers.
 Any healthcare provider, healthcare clearinghouse or healthcare organization
that conducts transactions or uses health records that fall under HIPPA
regulations is required to obtain an NPI.
How to get NPI?
 To get an NPI number provider need to apply through the National Plan and
Provider Enumeration System (NPPES).
NPPES website Link: www.nppes.cms.hhs.gov
There are basically two types of MPI Numbers issued:
Type 1 – issued to an individual Provider
Type 2 - Issued to group/Practice (institutions)

You can search detail of any NPI from the NPI directory below:
www.npiregistry.cms.hhs.gov/search

if you will search by NPI number of your provider on this above provided link, all
th details of doctor will be displayed.
CHAP #52 What is Taxonomy in US Healthcare

 Taxonomy codes are administrative codes that identify the practitioner type and
specialty for health care practitioners.
 In our previous lecture we study about NPI, so when will go to website for
getting NPI number in that case we must have Taxonomy number.
 Each taxonomy code is unique ten-character alphanumeric code that enables
practitioners to identify their specialty at the claim level.
 Taxonomy codes are assigned at both the individual practitioner and
organizational level.
 Taxonomy codes registered with NPPES at the time of NPI application is filled to
obtain NPI.
 A practitioner can have more than one taxonomy code, due to training, board
certifications etc.
 The taxonomy code is placed in box 24j and in box 33b preceded with “ZZ”
qualifier.

CHAP #53 What is NDC in US Healthcare

 The term National Drug Code (NDC) is referred to a unique three segment
number that is used to identify the report drug products.
 NDC is used to uniquely identify all drugs. The Food and Drug Administration
(FDA) is responsible to publish NDC number and update NDC directory.
 Each NDC Number is unique 10-digit number that is divided into 3 segments.
NDC contain following three segments:
1. Labeler Code: (5- digits)
What it is: The labeler code is like the drug's unique ID. It identifies the company
or manufacturer that produces the medication.
Example: If a company named ABC Pharmaceuticals makes a drug, their labeler
code will be a specific set of numbers.
2. Product Code: (3-digits)
What it is: The product code specifies the specific drug itself. It's indicate the
formula and strength of medicine.
Example: If ABC Pharmaceuticals makes both aspirin and ibuprofen, the product
code will distinguish between these two different drugs.
 3. Package Code: (2-digit)
What it is: The package code indicates the packaging size or type of the drug. It
helps identify whether it's a bottle, box, or some other form of packaging.
Example: If ABC Pharmaceuticals sells aspirin in both 50-tablet and 100-tablet
bottles, the package code will differentiate between these two packaging
options.

CHAP #54 What is EDI & Different types of Electronic Formats

What is EDI?
 Electronic data interchange in healthcare is a secure way of transmitting data
between healthcare institutions, insurer, and patients using established
message format and standard.
 It involves all electronic transmission of healthcare data between computer
systems and applications without any human interventions.

Types of different EDI

 270 & 271 – Eligibility benefit inquiry and response.
 837 – Used to send claim information to insurance.
 835 (ERA response) – Used by payers to make payments and send electronic
remittances.
 276 – used to check claim status with payers.

CHAP #55 What is the Tax ID & W-9 in US Healthcare

 Tax ID is very important part of credentialing, which is used for participating the
provider with insurance or staring a new practice.
 A TIN is a special number assigned by the government to identify a healthcare
provider or organization for tax and billing purposes.
 A taxpayer identification Number (TIN), in the United States, is a unique 9-digit
number for identifying an individual, business or other entity in tax returns and
additional documents filed with the internal Revenue Service (IRS).
 It is used in Box 25 in CMS1500 claim form.
 Tax id (show company or individual identification) is different than Taxonomy
code (used for provider specialty).
NOTE: Tax Identification Number in medical billing is like a healthcare provider's
or organization's ID for financial transactions. It ensures that billing and payments
are accurately recorded and processed in the healthcare system.
 w-9 form is an Internal Revenue Service (IRS) tax form that is used to confirm
person name, address, and taxpayer identification number (TIN) for
employment or other income generating purposes.
 W-9 form could be downloaded from IRS website.
 You can download and fill the w-9 form from the link given in description and
get it signed by the provider.