Archive for the ‘Medical Coding’ Category

List of AAPC Credentials

March 12, 2014

The American Academy of Professional Coders has medical coding certifications for several types of credentials. Each organization offers several types of credentials, some parallel each other like the CPC and CCS, while other credentials may be unique to the organization. Credentials that you can obtain are as follows:

CPC-A: Certified Professional Coder, Apprentice

CPC: Certified Professional Coder

CPC-P: Certified Professional Coder – Payer

CPC-H: Certified Professional Coder – Hospital

CPC-I: Certified Professional Coder – Instructor

Specialty Medical Coding Credentials are as follows:


List of HCPCS Categories

December 11, 2013

The letters at the beginning of HCPCS Level II codes have the following meanings:

  • A-codes (example: A0021): Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental
  • B-codes (example: B4034): Enteral and Parenteral Therapy
  • C-codes (example: C1300): Temporary Hospital Outpatient Prospective Payment System
  • D-codes: Dental Procedures
  • E-codes (example: E0100): Durable Medical Equipment
  • G-codes (example: G0008): Temporary Procedures & Professional Services
  • H-codes (example: H0001): Rehabilitative Services
  • J-codes (example: J0120): Drugs Administered Other Than Oral Method, Chemotherapy Drugs
  • K-codes (example: K0001): Temporary Codes for Durable Medical Equipment Regional Carriers
  • L-codes (example: L0112): Orthotic/Prosthetic Procedures
  • M-codes (example: M0064): Medical Services
  • P-codes (example: P2028): Pathology and Laboratory
  • Q-codes (example: Q0035): Temporary Codes
  • R-codes (example: R0070): Diagnostic Radiology Services
  • S-codes (example: S0012): Private Payer Codes
  • T-codes (example: T1000): State Medicaid Agency Codes
  • V-codes (example: V2020): Vision/Hearing Services

Billing Q&A: What are HCPCS?

December 4, 2013

HCPCS stands for Healthcare Common Procedure Coding System (HCPCS). For Medicare and other health insurance programs to ensure health care claims are processed in an orderly and consistent manner, standardized coding systems are essential. The HCPCS Level II code set is one of the standard code sets used by medical coders and billers for this purpose. The other, HCPCS Level I, is comprised of CPT (Current Procedural Terminology), copyrighted by the American Medical Association (AMA).

Sometimes described as the “hall closet of coding,” HCPCS Level II serves several needs. The HCPCS Level II code set is made up of five-character alpha-numeric codes representing primarily medical supplies, durable medical goods, non-physician services and services not represented in the Level I code set (CPT®). HCPCS Level II includes services such as ambulance, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when used outside a physician’s office. It is also used as an official code set for outpatient hospital care, chemotherapy drugs, Medicaid and other services. The Blue Cross Blue Shield Association and the American Dental Association (ADA) post their procedure codes as part of HCPCS Level II. The Centers for Medicare & Medicaid Services (CMS) often uses HCPCS Level II to post codes for the tracking of demonstration projects and new technologies.

The development and use of HCPCS Level II began in the 1980s. In 2003, the Secretary of Health and Human Services (HHS) delegated authority under the Health Insurance Portability & Accountability Act of 1996 (HIPAA) legislation to CMS to maintain and distribute HCPCS Level II codes. The code set is updated quarterly based on public input, which includes feedback from providers, manufacturers, vendors, specialty societies, the ADA, Blue Cross and others.

Billing Q&A: Covering for a Colleague

November 6, 2013

In part of our Question & Answer Series, today we address a common question about how to do billing when you are covering for another physician.

Q:  If I am covering for another physician and see some of his/her patients during his/her absence, are these patients considered new or established?

A:  The CPT guidelines specifically address this in the E/M services guidelines section in the front of the CPT manual, under the heading “New and Established Patient”.  “In the instance where a physician is on call for or covering for another physician, the patient’s encounter will be classified as it would have been by the physician who is not available.”

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

So what does this mean?  Let’s use an example.  Physician A is on vacation and Physician B is taking Call Coverage while the physician is out of town.  Patient makes an appointment to see On Call Physician (Physician B).  Patient is established with Physician A and would have seen Physician A except he/she is out of town.  Therefore the visit is billed as an Established Patient.

How do you get physicians to buy into ICD-10?

July 10, 2013

Each phase is the prerequisite for the next. Acquiring physician “buy‐in” must be accomplished in order to proceed to the planning and implementation phases. Because many physicians don’t know what they need to know about ICD‐10 in order to implement, analyze, and make informed choices, most practices are currently in Phase One: Engaging and educating physicians and staff. Take the time to create the foundation for the awareness and education necessary to achieve transition success and ensures you know ICD‐10 and that it is an opportunity for your organization and not a predicament.

Write your boss a letter like this:

“Doctor, thank you for all you do. Thank you for taking such great care of your patients and for taking such great care of your staff. We appreciate you and will do whatever we can to ensure the success of our practice. You always said
we could come to you if we had some thing really important to talk to you about. Well…this is really important.

As you know, we are talking about getting the practice ready for the ICD‐10 transition. You have committed budget to make sure we receive proper training. We are scheduling extra hours so we can have time to learn the new system. We are working with our IT vendors and business partners to make sure our software has been tested and ready to submit claims. We have made a good plan. Everything will be ready but we are concerned. Without you capturing the new documentation elements in order for us to be able to submit a properly coded claim, all the planning, budget, and new technology will be wasted. All the training hours and time away from our daily duties will be for naught. You see, it all starts with you. If you don’t document, all the planning, training, and technology in the world can’t help us.

The new codes are SO specific, documentation elements you’ve never had to capture before must be recorded or we can’t submit a claim. Denied claims due to insufficient documentation and therefore unspecific codes will cause a
rippling effect that means we have to chase you down in order to re‐submit. We are already so busy with our day‐to‐day duties it will be difficult to find time to do the extra work that would not have been necessary had you just recorded what was needed in the first place. I am asking you to do this for us but mostly…this is for you. We want you to continue to be able to give amazing care to our patients and to us. We want you to continue to be successful. We want you to know we care enough to write this note to you in the first place.

So, Doc, we promise we’ll be ready. All we ask is this. Help us help you.”
– Letter written by

ICD‐9 AND ICD‐10 Diagnosis Code Format and Differences

June 26, 2013

ICD‐9‐CM diagnosis codes vs ICD‐10‐CM diagnosis codes

  • 3‐5 characters in length vs 3‐7 characters in length
  • Approximately 14,000 codes vs Approximately 69,000 available codes
  • First digit may be alpha (E or V) or numeric & Digits 2‐5 are numeric vs Digit one is alpha & Digits two and three are numeric & Digits 4‐7 are alpha or numeric
  • Limited space for adding new codes vs Flexible for adding new codes
  • Lacks detail vs Very specific
  • Lacks laterality vs Has laterality
  • Difficult to analyze data due to nonspecific codes vs Specificity improves coding accuracy and richness of data for analysis
  • Codes are non‐specific and do not adequately define diagnosis needed for medical research vs Detail improves the accuracy of data used for medical research
  • Does not support interoperability because it is not used by other countries vs Supports interoperability and the exchange of health data between other countries and the United States

Why do we need ICD-10?

June 19, 2013

ICD‐9‐CM is outdated, over 30 years old, and cannot adequately accommodate the dramatic advances in
medicine and medical terminology. Many categories are full and not descriptive enough. Originally utilized for indexing purposes in the hospital inpatient setting, it was never intended to be part of the reimbursement process.

An effective coding system needs to be:

  • Flexible enough to quickly incorporate emerging diagnoses
  • Specific enough to precisely identify diagnoses and procedures resulting in
    • a reduction in claims denials due to increased granularity
    • improved coding accuracy
  • Able to support health IT and data exchange initiatives facilitating
    • data exchange between the U.S. and other countries
    • public health surveillance
    • improved quality of care measures and disease management

The ICD-10-CM Foundation and Background

June 12, 2013

Definition of Terms

In order to be able to discuss the transition from ICD‐9‐CM to ICD10‐CM, you first need to understand
the “language” in which the new coding process communicates. Following are terms you need to know.

Important Terms for ICD-10

Covered Entity: Providers, payers and clearinghouses who conduct specific administrative transactions electronically.

EDI: Electronic Data Interchange. Usually used in conjunction with the transmission of health data between providers and clearinghouses/insurance payers.

EHR: Electronic Health Record. This acronym is interchangeable with EMR (Electronic Medical Record). Generally means software that digitally stores patient charts and automates patient care functions such as computerized order entry and ePrescribing.

GEMs: “General Equivalence Mapping” is an approximate conversion and reference
mapping system that attempts to include all valid relationships between the codes in ICD‐9‐CM and ICD‐10‐CM. The relationships can be “one to many,” “many to one,” and in some cases, “one to one.” GEMs is an excellent tool to be used for ICD‐10‐CM staff training and chart auditing.

HIPAA: Health Insurance Portability and Accountability Act of 1996 established not just new rules for ensuring the privacy of health records but also set standards for the electronic transaction of interchanged health data.

HHS: The U.S. Department of Health and Human Services.

ICD‐9‐CM: The Diagnosis Coding lexicon currently in use. It is outdated, inflexible and many categories are full. ICD‐9‐CM contains approximately 13,000 diagnosis codes using a 5 numeric character structure and is electronically communicated using the traditional v.4010 data format.

ICD‐10‐CM: The Diagnosis Coding lexicon mandated for use on Oct. 1, 2014. Developed by World Health Organization (WHO), and used in most industrialized nations, this code structure requires a new data format (v.5010) because it contains up to 7 alphanumeric characters unlike the 5 numeric characters used in ICD‐9‐CM. Comprised of approximately 68,000 codes, it requires providers to code and document to much greater “specificity”.

ICD‐10‐PCS: For use in Inpatient Hospital procedure coding only. Physician outpatient settings will continue to use CPT‐4 to report procedures and services.

O.N.C.: Stands for the Office of the National Coordinator for Health Information
Technology and is a division of the U.S. Department of Health and Human Services (HHS). Under ONC, there are three bodies that can certify Electronic Medical Record technology for “Meaningful Use”.

Placeholder: When a seven character ICD‐10‐CM code requires a seventh character but the sixth position character has no function (e.g. no category, etiology or location), a “placeholder” consisting of the letter “X” is inserted in the sixth character position in order to hold that place in the code so that a seventh character can be used.

PM Software: “Front End” practice management software that schedules, tracks and codes patient encounters. (As opposed to the automated charting functions of EMR).

R.A.C. Audit: Recovery Audit Contractor ‐ The RAC Program’s purpose is to reduce improper Medicare payments and implement actions to prevent future improper payments. The demonstration program in 3 states started in 2005. 3 more states were added and by 2008, $1.03 billion were recovered from improper payments.

Role Based: Used to describe a type of training strategy that focuses the amount and type of training on job classification rather than general training for an entire group. In this context for example, you should consider a different level of training for your physicians (documentation training) than for your coding staff (full ICD‐10‐CM training).

Sequela: An aftereffect of a disease, condition or injury. Also called a “late effect.”

Specificity: In this context, “specificity” is a term used to describe choosing the diagnosis code that is the most descriptive possible given the available provider documentation.

V.5010: An electronic data reporting format scheduled replacing V.4010 on Jan. 1, 2012. Electronic testing of transactions using V.5010 commenced on Jan. 1, 2011. This new data format is required because the new ICD‐10‐CM codes are comprised of up to 7 alpha numeric characters and the old data format currently in use (v.4010) is unable to accommodate ICD‐10‐CM. (On Nov 17, 2011 CMS announced a 90‐Day period of enforcement discretion.)

W.E.D.I.: Comprised of a cross section of the health care industry, the Workgroup for Electronic Data Interchange (WEDI) is the leading authority on the use of Health IT to improve healthcare information exchange in order to enhance the quality of care, improve efficiency and to reduce costs of the American healthcare system. Formed in 1991 by the Secretary of Health and Human Services (HHS), WEDI was named in the 1996 HIPAA legislation as an advisor to HHS and continues to fulfill that role today.

WHO: World Health Organization is made up of representatives from numerous
countries that create policy and develop health programs to be adopted on a
world‐wide basis. The WHO developed ICD‐10.

ICD-10 is delayed another year…

April 11, 2012

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced Monday, April 9th, a proposed rule that would establish a unique health plan identifier under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The proposed rule would implement several administrative simplification provisions of the Affordable Care Act.

The proposed changes would save health care providers and health plans up to $4.6 billion over the next ten years, according to estimates released by the HHS today. The estimates were included in a proposed rule that cuts red tape and simplifies administrative processes for doctors, hospitals and health insurance plans.

“The new health care law is cutting red tape, making our health care system more efficient and saving money,” Secretary Sebelius said. “These important simplifications will mean doctors can spend less time filling out forms and more time seeing patients.”

Currently, when health plans and entities like third-party administrators bill providers, they are identified using a wide range of different identifiers that do not have a standard length or format. As a result, health care providers run into a number of time-consuming problems, such as routing errors of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility.

The rule simplifies the administrative process for providers by proposing that health plans have a unique identifier of a standard length and format to facilitate routine use in computer systems.  This will allow provider offices to automate and simplify their processes, particularly when processing bills and other transactions.

The proposed rule also delays required compliance by one year– from Oct. 1, 2013, to Oct. 1, 2014– for new codes used to classify diseases and health problems. These codes, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes, or ICD-10, will include new procedures and diagnoses and improve the quality of information available for quality improvement and payment purposes.

Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date. The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.

The proposed rule announced today is the third in a series of administrative simplification rules in the new health care law. HHS released the first in July of 2011 and the second in January of 2012, and plans to announce more in the coming months.

More information on the proposed rule is available on fact sheets at

The proposed rule may be viewed at Comments are due 30 days after publication in the Federal Register.

How does the Prompt Pay Law affect Non-Contracted Providers?

September 26, 2011

The Texas Department of Insurance oversees and handles all complaints from physicians and providers about carriers who are failing to comply with the prompt payment requirements of Articles 3.70-3C, §3A and 20A.18B of the Texas Insurance Code and Department rules.  The Department is committed to achieving full company compliance with the prompt payment statutes and rules.

This article is to remind you of your responsibility to comply with the prompt payment laws for non-contracted physicians and providers and review some basic requirements that carriers must follow for making prompt payments to non-contracted physicians and providers.

For complete information on all of the required claims processing procedures to comply with Texas statutes and Department rules, refer to the appropriate provisions of the Texas Insurance Code and the Texas Administrative Code. Also, review the Prompt Payment Statutes and rules to verify that your internal procedures comply with these requirements.


Fee-for-service (indemnity plans) and preferred provider plans. When there is no contractual relationship between the physician or provider and the insurer, the insured may make an assignment of benefits to the physician or provider. This includes instances in which an insured in a fee-for-service or indemnity plan makes an assignment of benefits to a physician or provider or if an insured in a preferred provider plan receives services from a non-network provider and makes an assignment of benefits. Under Article 3.51-6, §1(d)(2)(x) (group health plans) and Article 3.70-3, §(A)(8) (11) (individual policies) of the Texas Insurance Code, the insurer must pay all benefits payable under the policy within 60 days after receipt of proof of loss.

HMOs. If an HMO enrollee receives services from a non-network physician or provider through a referral (as outlined in Article 20A.09(a)(3)(C)) of the Texas Insurance Code or emergency services from a non-network physician or provider (no referral needed), the HMO must make payment to the non-network physician or provider within 45 days after receiving the claim. The claim must include documentation reasonably necessary to process the claim and must be for covered services, as provided in Article 20A.09(j).

In situations where the enrollee or insured does not make an assignment of benefits or an authorization of payment to the physician or provider, the HMO or insurer will directly reimburse the enrollee or insured. The physician or provider can then obtain payment from the enrollee or insured.


The Department investigates all complaints alleging non-compliance with the requirements of the prompt payment statutes and rules. If allegations are substantiated, the Department may impose any authorized sanctions and penalties, including suspension or revocation of the carrier´s license to conduct the business of insurance in Texas. Other regulatory compliance options include administrative oversight, commissioner´s orders with fines, corrective action plans, management conferences, and reporting/monitoring requirements. In addition, if allegations of violation of Articles 3.70-3C, §3A and 20A.18B and 28 TAC §§21.2801-21.2815 are substantiated, the Department may impose administrative penalties of up to $1,000 per day for each claim that remains unpaid in violation of the prompt payment requirements.

How does the Prompt Pay Law affect Contracted Providers?

September 19, 2011

The Texas Department of Insurance oversees and handles all complaints from physicians and providers about carriers who are failing to comply with the prompt payment requirements of Articles 3.70-3C, §3A and 20A.18B of the Texas Insurance Code and Department rules.  The Department is committed to achieving full company compliance with the prompt payment statutes and rules.

This article is to remind you of your responsibility to comply with the prompt payment laws for contracted physicians and providers and highlights some basic requirements that carriers must follow for making prompt payments to contracted physicians and providers.

For complete information on all of the required claims processing procedures to comply with Texas statutes and Department rules, refer to the appropriate provisions of the Texas Insurance Code and the Texas Administrative Code. Also, review the prompt payment statutes and rules to verify that your internal procedures comply with these requirements.


Applicable Statutes and Rules. Article 3.70-3C, §3A specifies claims processing procedures and prompt payment requirements for preferred provider carriers when processing claims filed by contracted physicians and providers. Article 20A.18B specifies these same types of requirements for HMOs.

The rules implementing these statutes are found at Title 28 of the Texas Administrative Code (TAC), §§21.2801-21.2815. The rules apply to all claims filed for non-confinement services, treatments, or supplies rendered on or after August 1, 2000, and to claims filed for services, treatments, or supplies for in-patient confinements in a hospital or other institution that began on or after August 1, 2000.

Statutory Timelines. If a physician or provider submits a “clean claim” as defined in §§21.2802 and 21.2803, the carrier has 45 days after receipt of the claim to do one of the following:

  • pay the total amount of the claim in accordance with the contract;
  • deny the entire claim after a determination that the carrier is not liable and notify the physician or provider in writing why the carrier will not pay the claim;
  • pay the undisputed portion of a claim and deny the remainder after a determination that the carrier is not liable for the remainder of the claim and notify the physician or provider in writing why the carrier will not pay the denied portion of the claim;
  • pay the undisputed portion of the claim, notify the physician or provider in writing that the remainder of the claim will be audited and pay the physician or provider 85 percent of the contracted rate on the unpaid portion of the claim; or
  • notify the physician or provider in writing that the entire claim will be audited and pay the physician or provider 85 percent of the contracted rate on the claim.

When a carrier acknowledges coverage but decides to audit a claim, it must pay 85 percent of the contracted rate on the claim within 45 days. After the audit is completed, the carrier must make any additional payment within 30 days. Physicians and providers who owe refunds to a carrier must make them within 30 days after the physician or provider receives the audit results, or after the exhaustion of any covered person´s appeal rights if the appeal is filed within the 30-day refund period, whichever comes later. A carrier that fails to comply with the claims payment requirements is liable for payment of the full amount of billed charges submitted on the claim or the contracted penalty rate set forth in the contract between the physician or provider and the carrier. In addition, the Department may impose regulatory remedies and sanctions for non-compliance (as explained in the Enforcement section of this bulletin).

For prescription benefit claims, the carrier must pay electronically submitted prescription claims that are electronically adjudicated and electronically paid within 21 days after authorizing treatment.

If you pend taking action on a clean claim without complying with these requirements, you are not in compliance with the clean claims rules.

Claims Address. The carrier is required by rule to disclose to the physician or provider the following information:

  • an address where claims are to be sent for processing;
  • a telephone number for questions regarding claims;
  • the name, address, and telephone number of any entity to which claims payment functions have been delegated; and
  • the address and telephone number of any separate claims processing centers.

A carrier may not, after a change of claims payment address or a change in delegation of claims payment functions, deny a clean claim on the basis that a physician or provider failed to file the claim within any contracted time period, unless the carrier provided at least 60 calendar days prior written notice of the address or delegation change. A carrier may not fail to acknowledge receipt of a claim sent by certified or registered mail.

If you change the address to which the physician or provider must send the claim and do not give the required written notice and subsequently fail to act upon a clean claim within the statutory payment period or refuse to accept a clean claim because it was sent to the incorrect address, you are not in compliance with the clean claims rules.

Alteration by Contract. Statutory requirements, such as the prompt payment periods, may not be changed by contract (except that the 45-day payment period may be shortened by contract). Carriers may alter by contract some of the prompt payment requirements such as data elements and attachment requirements.

If you use contract provisions to lengthen the statutory prompt payment periods, you are not in compliance with the clean claims rules.

Attachments and Additional Elements. Carriers may revise their requirements for additional attachments and clean claims elements upon proper notification. The physician or provider must be notified at least 60 calendar days before the carrier may require the additional attachment or element.

If you are requiring physicians or providers to submit attachments for which you have not given proper notification in accordance with the rules, you are not in compliance with the clean claims rules.

Prompt Pay Law definition

September 12, 2011

Prompt Payment to Providers

28 TAC §§21.2801-21.2816

When Does a Company Have to Pay a Claim for a Health Service?

  • Texas law provides different requirements depending upon:
    • Type of coverage – HMO vs. PPO vs. Non-network Indemnity
    • Who filed the claim – Insured, Enrollee, Physician, or Provider
    • Status of physician or provider – Contracted vs. Non-contracted

Clean Claim Rules

Meant to implement and clarify HB 610 passed during 1999 legislative session

  • Apply to:
    • HMOs
    • PPOs
    • Contracted Physicians and Providers
  • Effective for:
    • Claims filed for outpatient care received on or after 8/1/00
    • Claims filed for inpatient stays that began on or after 8/1/00
  • Clean Claim Rules
  • Perform three main functions:
    • Define elements of a clean claim
    • Clarify when the prompt payment period clock starts running
    • Clarify the required actions of a carrier upon receipt of a clean claim

What is a Clean Claim?

  • Data elements – see handouts
    • HCFA 1500
    • UB-92
  • Attachments
  • Additional clean claim elements
  • Format
    • Legible, accurate, complete
    • Too much information does not render an otherwise clean claim deficient!

Proof of Claims Submission

  • Return receipt
  • Electronic confirmation
  • Fax confirmation

What are the Carrier´s Responsibilities?

  • Notice of revised or additional data elements and/or attachments. Disclosure may be made by:
    • Written notice at least 60 days prior to requiring additional or revised information
    • Revision of physician or provider manual at least 60 days prior to requiring additional or revised information
    • Contract provisions
  • Act on clean claims within 45-day statutory claims processing period
    • Pay the claim, in total, in accordance with the contract
    • Deny the claim in total and notify the physician or provider in writing of the reason for denial
    • Pay portion and deny portion, and notify physician or provider in writing of reason for denial
    • Pay portion and audit portion, notify physician or provider in writing that claim is being audited, and pay 85% of the contracted rate on the audited portion
    • Audit entire claim, notify physician or provider in writing that claim is being audited, and pay 85% of the contracted rate
  • Notice of deficient claims within 45 days
  • Notice of changes in claims addresses, processors, etc.


  • Carrier acknowledges coverage of an enrollee, but claim processing takes longer than the 45-day statutory claim processing period
  • The rule does not specify a time limit for audit completion
  • After the audit is completed the carrier must give written notice of the results and pay the additional 15% balance of contracted rate 30 days after the audit is completed
  • A physician or provider must refund the 85% audit payment:
    • 30 days after the later of (a) receiving notice of audit results, or (b) exhaustion of enrollee’s appeal rights, if appealed within 30-day refund period
    • Chargebacks are allowed with written notice and opportunity to arrange an alternative reimbursement method

Penalties if Carriers Fail to Comply with the Clean Claim Rules

  • Full amount of billed charges up to U&C charges, or
  • Contracted penalty rate provided for in the physician or provider’s contract
  • Administrative penalties, up to $1,000/day per claim, may be assessed and collected by the State of Texas

Date of Claim Payment

  • Claim is considered to have been paid on the date of:
    • U.S. Postal Service postmark
    • Electronic transmission
    • Delivery of the claim payment to a commercial carrier, such as UPS or Federal Express, or
    • Receipt by the physician or provider, if a claim payment is made other than provided above

Coordination of Benefits

  • The amount(s) paid by primary carrier(s) is a clean claim element for secondary carriers
  • The statutory claim processing period for secondary carriers does not begin until primary payor information is provided

Essential Data Elements for a HCFA1500

September 6, 2011


Data Elements that are required:

Field # Data Element
1a Subscriber´s or patient´s plan ID number
2 Patient´s name
3 Patient´s date of birth and gender
4 Subscriber´s name
5 Patient´s address (street or post office box, city, zip)
6 Patient´s relationship to subscriber
7 Subscriber´s address
10 Whether patient´s condition is related to employment, auto accident, or other accident
11 Subscriber´s policy number
11a Subscriber´s birth date and gender
11c HMO or preferred provider carrier name
11d Disclosure of any other health benefit plans*
12 Patient´s or authorized person´s signature or notation that the signature is on file with the physician or provider
13 Subscriber´s or authorized person´s signature or notation that the signature is on file with the physician or provider
14 Date of current illness, injury or pregnancy
15 First date of previous, same or similar illness
21 Diagnosis codes or nature of illness or injury
24A Date(s) of service
24B Place of service codes
24C Type of service code
24D Procedure/modifier code
24E Diagnosis code by specific service
24F Charge for each listed service
24G Number of days or units
25 Physician´s or provider´s federal tax ID number
28 Total Charge
31 Signature of physician or provider or notation that the signature is on file with the HMO or preferred provider carrier
32 Name and address of facility where services were rendered (if other than home or office)
33 Physician´s or provider´s billing name and address

(unless otherwise agreed to by contract)

* If answer in field 11d is “Yes”, then data elements in fields 9, 9a, 9b, 9c, and 9d must be completed. If answer is “No”, then fields 9, 9a, 9b, 9c, and 9d are not essential data elements if the physician or provider has on file a statement signed by the patient/insured within the last 12 months that there is no other coverage. Such statement may be in the form of initial or annual office visit questionnaires, patient sign-in sheets, a routine record update, etc.


Data Elements that are necessary, if applicable:

Field # Data Element
9 Other insured´s or enrollee´s name – applicable if Field 11d is answered “yes”*
9a Other insured´s or enrollee´s policy/group number – applicable if Field 11d is answered “yes”*
9b Other insured´s or enrollee´s date of birth – applicable if Field 11d is answered “yes”*
9c Other insured´s or enrollee´s plan name (employer, school, etc) – applicable if Field 11d is answered “yes”*
9d Other insured´s or enrollee´s HMO or insurer name – applicable if Field 11d is answered “yes”*
11b Subscriber´s plan name (employer, school, etc.) – applicable if health plan is a group plan
23 Prior authorization number – applicable when prior authorization is required
27 Whether assignment was accepted – applicable when assignment under Medicare has been accepted
29 Amount paid – applicable if an amount has been paid by or on behalf of the patient or subscriber or by a primary plan
30 Balance due – applicable if an amount has been paid by or on behalf of the patient or subscriber

(unless otherwise agreed to by contract)

* If answer in field 11d is “Yes”, then the data elements in fields 9, 9a, 9b, 9c, and 9d must be completed unless the physician or provider submits proof of a good faith but unsuccessful effort to obtain this information from the enrollee/insured.

Information needed for filing Insurance Claim Complaints

August 22, 2011

Know Your Claim Filing Requirements

  • Know your contractual obligations, including where to file claims, claim filing deadlines and your fee schedule
  • File claims to the correct claims filing address
  • File claims with carriers in a timely manner
  • File claims using a method that will document when the claim was received by the carrier
  • Keep records of your phone conversations and all written correspondence with each carrier regarding the status of a claim
  • Update your accounts receivables as soon as claim payments are received
  • Don´t submit duplicate bills. If there is a genuine need to send a duplicate bill to a carrier, mark it clearly as a duplicate

Keep Documentation for Filing Complaints

Be sure to include the following when filing a complaint with the Texas Department of Insurance (TDI) regarding a delay in claim payment:

  • A copy of the patient´s health insurance ID card
  • A copy of the claim submitted to the company for each patient and date of service
  • Evidence of claim submission in the form of:
    • Electronic transmission confirmation,
    • Certified mail return receipt, or
    • Courier delivery confirmation
  • Evidence of your collection activities for each claim prior to contacting TDI. That evidence should be in the form of:
    • Documentation of phone conversations made to the health carrier
    • Copies of correspondence mailed to the health carrier
    • Replies you have received from the health carrier

Be sure to separate claims by the HMO or insurance carrier name. Claims for one HMO or insurance carrier must be grouped together and alphabetized by the patient’s last name. If there is more than one claim for the same patient, please staple the claims together.  To find where to submit an insurance complaint to, check the list here.

For more information contact:

How can I prepare for ICD-10?

March 28, 2011

What can I do to prepare for ICD-10-CM?

While there will need to be significant education and training for physicians, coders and other health care personnel to fully implement this major code change, no one needs to panic. Other organizations are already attempting to capitalize on the situation by suggesting that coders should begin training immediately. The AAPC does not believe such an approach is either necessary or prudent since it will likely be difficult to remember in three or four years what you were trained on today.

The AAPC has a plan in place to provide accurate and timely assistance to permit you to effectively implement ICD-10 on time.  The plan is broken down by year (2009 – 2013) and includes a variety of delivery methods, such as Webinars, audio conferences, onsite training and national and regional conferences. A team of leading coding and ICD-10 experts developed the plan, which is broken into benchmarked steps.

As part of the implementation plan, the AAPC has provided its members with a “Personal Progress Tracker,” which gives members the ability to easily enter in personal progress with red, yellow and green lights that indicate whether the member is on schedule or not. More information, including the detailed plan and training program, is available on the AAPC’s Web site at

What is ICD-10?

March 21, 2011

What is ICD-10?

ICD-10 is a diagnostic coding system implemented by the World Health Organization (WHO) in 1993 to replace ICD-9, which was developed by WHO in the 1970s. ICD-10 is in almost every country in the world, except the United States.

When we hear “ICD-10” in the United States, it usually refers to the U.S. clinical modification of ICD-10: ICD-10-CM. This code set is scheduled to replace ICD-9-CM, our current U.S. diagnostic code set, on Oct. 1, 2013.

Another designation, ICD-10-PCS, for “procedural coding system,” is will also be adopted in the United States. ICD-10-PCS will replace Volume 3 of ICD-9-CM as the inpatient procedural coding system. Current plans would see CPT remain the coding system for physician services.

More information on WHO’s ICD-10 code set can be found at

When will ICD-10-CM and ICD-10-PCS be implemented?

The Department of Health and Human Services (HHS) announced on August 15, 2008, a long-awaited proposed regulation that would replace the ICD-9-CM code sets now used to report health care diagnoses and procedures with greatly expanded ICD-10-CM (diagnosis) and ICD-10-PCS (hospital procedure) code sets. In a separate proposed regulation, HHS has proposed adopting the updated X12 standard, Version 5010, and the National Council for Prescription Drug Programs standard, Version D.0, for electronic transactions, such as health care claims. Version 5010 is essential to use of the ICD-10 codes.

The Centers for Medicare and Medicaid Services (CMS) announced in January that ICD-10-CM will be implemented into the HIPAA mandated code set on Oct. 1, 2013. The American Academy of Professional Coders (AAPC) lobbied successfully to delay implementation beyond its initial 2010 proposed date, and more recently to delay a proposed 2011 date, believing that it would create undue hardships in the industry, as it falls too soon on the heels of other significant regulatory changes that have burdened providers in recent years.

Why is the United States moving to ICD-10-CM?

ICD-9-CM has several problems. Foremost, it is out of room. Because the classification is organized scientifically, each three-digit category can have only 10 subcategories. Most numbers in most categories have been assigned diagnoses. Medical science keeps making new discoveries, and there are no numbers to assign these diagnoses.

Computer science, combined with new, more detailed codes of ICD-10-CM, will allow for better analysis of disease patterns and treatment outcomes that can advance medical care. These same details will streamline claims submissions, since these details will make the initial claim much easier for payers to understand.

How is ICD-10-CM different from our current system?

In many ways, ICD-10-CM is quite similar to ICD-9-CM. The guidelines, conventions, and rules are very similar. The organization of the codes is very similar. Anyone who is qualified to code ICD-9-CM should be able to easily make the transition to coding ICD-10-CM.

Many improvements have been made to coding in ICD-10-CM. For example, a single code can be found to report a disease and its current manifestation (i.e., type II diabetes with diabetic retinopathy). In fracture care, the code differentiates an encounter for an initial fracture; follow-up of fracture healing normally; follow-up with fracture in malunion or nonunion; or follow-up for late effects of a fracture. Likewise, the trimester is designated in obstetrical codes.

While much has been said about the huge increase in the number of codes under ICD-10-CM, some of this growth is due to laterality. While an ICD-9-CM code may identify a condition of, for example, the ovary, the parallel ICD-10-CM code identifies four codes: unspecified ovary, right ovary, left ovary, or bilateral condition of the ovaries.

The big differences between the two systems are differences that will affect information technology and software at your practice. Here’s a chart showing the differences:

Issue ICD-9-CM ICD-10-CM
Volume of codes approximately 13,600 approximately 69,000
Composition of codes Mostly numeric, with E and V codes alphanumeric. Valid codes of three, four, or five digits. All codes are alphanumeric, beginning with a letter and with a mix of numbers and letters thereafter. Valid codes may have three, four, five, six or seven digits.
Duplication of code sets Currently, only ICD-9-CM codes are required . No mapping is necessary. For a period of up to two years, systems will need to access both ICD-9-CM codes and ICD-10-CM codes as the country transitions from ICD-9-CM to ICD-10-CM. Mapping will be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits and outcomes studies.

What is an Advanced Beneficiary Notice (ABN)?

March 14, 2011
ABN (Advanced Beneficiary Notice):  

An ABN is a written notice from Medicare (standard government form CMS-R-131), given to you before receiving certain items or services, notifying the patient:

• Medicare may deny payment for that specific procedure or treatment.

• The patient will be personally responsible for full payment if Medicare denies payment.

An ABN gives the patient the opportunity to accept or refuse the items or services and protects the patient from unexpected financial liability in cases where Medicare denies payment. It also offers the patient the right to appeal Medicare’s decision. You follow office policy on keeping the ABN form on file and you ad the modifier GA to the claim. Modifier GA informs Medicare of the ABN transaction. If you do not have the patient sign the ABN form and the claim is denied, then you cannot bill the patient for the denied claim.

The patient has the option to receive the items or services or to refuse them. In either case, the patient should choose one option on the form by checking the box provided, and then signing and dating it in the space provided.

When the patient signs an ABN and becomes liable for payment, the patient will have to pay for the item or service themselves, either out-of-pocket or by some other insurance coverage which they may have in addition to Medicare. Medicare fee schedule amounts and balance billing limits do not apply. The amount of the bill is a matter between the patient and provider. If this is a concern for the patient, they might want to ask for a cost estimate before they sign the ABN.

7 Things Every Medical Biller Should Know

March 7, 2011

1.       Rules & Regulations

Have an understanding of the rules and regulations set forth by each and every entity: 

  • Centers for Medicare & Medicaid Services (CMS)
  • American Medical Association (AMA)
  • Health Insurance Portability and Accountability Act (HIPAA)
  • Office of Inspector General (OIG)
  •  State Laws (per your state) – a resources for Texas:  Texas Department of Insurance (TDI), Texas Medical Board (TMB), Texas Medical Association (TMA), and Tarrant County Medical Society (TCMS)
  • US Department of Health and Human Services (HHS)
  • The Fair Debt Collection Practices Act (FDCPA)
  • Protected Health Information (PHI)
  • Insurance Payers specifications & regulations
  • Prompt Pay Act



2.       Obtain Copies of your Insurance Contracts

The importance of having copies of your contracts with the payer’s is so that you are aware of the physician’s legal obligations, agreed upon terms, and defined requirements to ensure that you adhere to their specific regulations.  It also defines other pieces of information that are helpful to you in dealing with medical claims.


3.       Make a list of your top 10 or 20 CPT Codes

This enables you to already have prepared your top codes when either an insurance company requests it or to submit to an insurance company to obtain their contract rates if you don’t otherwise have them.  Make sure that this procedure code list is current and up-to-date.


4.       Medical Terminology

Be familiar with the medical terminology of your field or practice specialty.  Research all the information available regarding the specific specialty of your practice.  This will provide you with an extensive amount of resources, knowledge at knowing the when, where, why & how’s for treatment, testing, medication, etc.  This will be a benefit to your advantage when you are trying to explain details and/or resolve issues with either insurance companies, patients or other entities.


5.       The Importance of Accuracy

Accuracy and attention to detail are key aspects of a medical biller’s success.  Accuracy affects the charge entry, claims processing, payment processing, appeals and collections processes.  If your data and processes are not accurate, you will spend exorbitant amounts of time, energy and even money tracking and pursuing claims.  You must be attentive and accurate in every aspect of the process to be efficient and effective in your role as a medical biller.


6.       Requires Organization and Persistence

Medical Billing requires that you be organized.  You need to know where all your files are kept, keep an original of all forms required, create a process with procedures in place to accomplish all duties from start to finish, and attend to the smallest details.

Medical Billing requires persistence on every level.   Pushing things off to a later date, letting things slide as not being important, giving up when you know the data you have is accurate, and not providing follow thru will not only hurt the reimbursement for you and your physician, it creates unnecessary issues and further paperwork along with additional follow-up which can be prevented.


7.       Read all literature you run across

We all get inundated with paperwork, newsletters and articles.  Remember that it is very important that you stay informed on the updates that are produced by various networks, organizations and companies.  Use this to your advantage so you never are caught unprepared or uneducated.


Utilize these 7 steps and you will have a foundation for becoming an excellent Medical Biller!  We wish you great success!  If we can assist you further, please to not hesitate to contact us at 817.239.6595.

Medical Billing Glossary

February 28, 2011

Account Number – Number you’re given by your doctor or hospital for a medical visit.

Actual Charge – The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount an insurance plan approves.

Adjustment – The portion of your bill that your doctor or hospital has agreed not to charge you.

Admission Date (Admit Date) – Date you were admitted for treatment.

Admission Hour – Hour when you were admitted for inpatient or outpatient care.

Admitting Diagnosis – Words that your doctor uses to describe your condition

Advance Beneficiary Notice (ABN) – A notice the hospital or doctor gives you before you’re treated, telling you that Medicare will not pay for some treatment or services. The notice is given to you so that you may decide whether to have the treatment and how to pay for it.

Advance Directive (Healthcare) – Written ahead of time, a health care advance directive is a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.

All-inclusive Rate – Payment covering all services during your hospital stay.

Ambulatory Payment Classifications (APC) – A Medicare payment system that classifies outpatient services so Medicare can pay all hospitals the same amount.

Ambulatory Care – All types of health services that do not require an overnight hospital stay.

Ambulatory Surgery – Outpatient surgery or surgery that does not require an overnight hospital stay.

Amount Charged – How much your doctor or hospital bills you.

Amount Paid – The dollar amount that you paid for your doctor or hospital visit.

Amount Not Covered – What your insurance company does not pay. It includes deductibles, co-insurances, and charges for non-covered services.

Amount Payable by Plan – How much your insurer pays for your treatment, minus any deductibles, co-insurance, or charges for non-covered services.

Ancillary Service – Services you need beyond room and board charges, such as laboratory tests, therapy, surgery and the like.

Anesthesia – Drugs given to you during surgery to eliminate or reduce surgical procedure pain. 

Appeal – A process by which you, your doctor, or your hospital can object to your health plan when you disagree with the health plan’s decision to not pay for your care.

Applied to Deductible – Portion of your bill, as defined by your insurance company, that you owe your doctor or hospital.

Assignment – An agreement you sign that allows your insurance to pay the doctor or hospital directly.

Assignment of Benefits – When insurance payments are sent directly to your doctor or hospital.

Attending Physician Name – The doctor who certifies that you need treatment and is responsible for your care.

Authorization Number – A number stating that your treatment has been approved by your insurance plan. Also called a Certification Number or Prior-Authorization Number.

Balance Bill – How much doctors and hospitals charge you after your health plan, insurance company, or Medicare have paid its approved amount.

Beneficiary – Person covered by health insurance.

Beneficiary Eligibility Verification – A way for doctors and hospitals to get information about whether you have insurance coverage.

Beneficiary Liability – A statement that you are responsible for some treatments or charges.

Benefit – The amount your insurance company pays for medical services.

Bill/Invoice/Statement – Printed summary of your medical bill.

Cardiology Charges – Charges for heart procedures. Examples are heart catheterization and stress testing.

Case Management – A way to help you get the care you need, especially when you need pre-authorized care from several services. Usually a nurse helps arrange for your care.

Centers for Medicare and Medicaid (CMS) – The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

CHAMPUS – Insurance linked to military service, also known as TriCare.

Charity Care – Free or reduced-fee care for patients who have financial hardship.

Claim – Your medical bill that is sent to an insurance company for processing.

Claim Number – A number given to a medical service.

Claims Review – The method by which a patient’s health care service claims are reviewed before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.

Clean Claim – A claim that does not have to be investigated by insurance companies before they process it.

Clinic – An area in a hospital or separate building that treats regularly scheduled or walk-in patients for non-emergency care.

COBRA Insurance – Health insurance that you can buy when you lose your job. It is generally more expensive than insurance provided through your job but less expensive than insurance purchased on your own when you are unemployed.

Coding of Claims – Translating diagnoses and procedures in your medical record into numbers
that computers can understand.

Co-insurance – The cost sharing part of your bill that you have to pay.

Co-insurance Days (Medicare) – Hospital Inpatient Medicare coverage from day 61 to-day 90 of continuous hospitalization. You are responsible for paying for part of those days. After the 90th day, you enter your “Lifetime Reserve Days”.

Collection Agency – A business that collects money for unpaid bills.

Consent (for treatment) – An agreement you sign that gives your permission to receive medical services or treatment from doctors or hospitals.

Contractual Adjustment – A part of your bill that your doctor or hospital must write off (not charge you) because of billing agreements with your insurance company.

Coordination of Benefits (COB) – A way to decide which insurance company is responsible for payment if you have more than one insurance plan.

Co-pay – Agreed amount of the charges for medical services that patients or guarantors must pay.

Coronary Care – Routine charges for care you receive in a heart center because you need more care than you can get in a regular medical unit.

Covered Benefit – A health service or item that is included in your health plan, and that is paid for either partially or fully.

Covered Days – Days that your insurance company pays for in full or in part.

CPT Codes – A coding system used to describe what treatment or services were given to you by your doctor.

CT Scan – A type of X-ray of the head or body; usually done in a hospital’s x-ray department.

Date of Bill – The date the bill for your services is prepared. It is not the same as the date of service.

Date of Service (DOS) – The date(s) when you were treated.

Days – The total number of days that you are being charged for the hospital’s services.

Deductible – How much cost sharing that you must pay for medical services often before your insurance company starts to pay.

Description of Services – Tells what your doctor or hospital did for you.

Diagnosis Code (ICD9 Code) – A code used for billing that describes your illness.

Diagnosis – Related Groups (DRGs) – A payment system for hospital bills. This system categorizes illnesses and medical procedures into groups for which hospitals are paid a fixed amount for each admission.

Discharge Hour – Hour when you were discharged.

Discount – Dollar amount taken off your bill, usually because of a contract with your hospital or doctor and your insurance company.

Drugs/Self Administered – Drugs that do not require doctors or nurses to help you when you take them. You may be charged for these. You will need to check with your doctor or hospital regarding their policy on this.

Due from Insurance – How much money is due from your insurance company.

Due from Patient – How much you owe your doctor or hospital.

Durable Medical Equipment (DME) – Medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.

EEG – Equipment or medical procedure that measures electricity in the brain.

EKG/ECG – Equipment or medical procedure that measures how your heart works, and your doctor’s reading of the results.

Eligible Payment Amount – Those medical services that an insurance company pays for.

Emergency Care – Care given for a medical emergency when you believe that your health is in serious danger when every second counts.

Emergency Room – A special part of a hospital that treats patients with emergency or urgent medical problems.

Estimated Insurance – Estimated cost paid by your insurance company.

Enrollee – A person who is covered by health insurance.

Estimated Amount Due – How much the doctor or hospital estimates you or your insurance company owes.

Exclusion – Services or supplies not covered under a health plan.

Explanation of Benefits (EOB/EOMB) – The notice you receive from your insurance company after getting medical services from a doctor or hospital. It tells you what was billed, the payment amount approved by your insurance, the amount paid, and what you have to pay.

External Cause of Injury Code – A code describing a place or item that may have caused injuries, poisoning, or health problems.

Federal Tax ID Number – A number assigned by the federal government to doctors and hospitals for tax purposes.

Fee Schedule  – A listing of the maximum fee which a health plan will pay for services based on CPT billing codes.

Financial Responsibility – How much of your bill you have to pay.

Fiscal Intermediary (FI) – A Medicare agent that processes Medicare claims.

Fraud and Abuse – Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by the insurance plan. This is not the same as fraud.

Guarantor – Someone who has agreed to pay the bill.

HCFA 1500 Billing Form – A form used by doctors to file insurance claims for medical services.

HCPCS Codes – A coding system used to describe what treatment or services were given to you by your doctor.

Health Care Financing Administration (HCFA) – Former name of the government agency now called the Centers for Medicare & Medicaid Services.

Healthcare Provider – Someone who provides medical services, such as doctors, hospitals, or laboratories. This term should not be confused with insurance companies that “provide” insurance.

Health Insurance – Coverage that pays benefits for sickness or injury. It includes insurance for accidents, medical expenses, disabilities, or accidental death and dismemberment.

Health Maintenance Organization (HMO) – An insurance plan that pays for preventive and other medical services provided by a specific group of participating providers.

HIPAA – Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your health information.

Home Health Agency – An agency that treats patients in their homes.

Hospice – Group that offers inpatient, outpatient, and home healthcare for terminally ill patients.

Hospital Inpatient Prospective Payment System (PPS) – A federal system that pays a fixed fee for inpatient care.

In-of-Network Provider – A doctor or other healthcare provider who is contracted as part of an insurance plan’s doctor or hospital network. Same as participating provider.

Incremental Nursing Charge – Charges for nursing services added to basic room and board charges.

Inpatient (IP) – Patients who stay overnight in the hospital.

Insurance Cap – An insurance cap is the total lifetime dollar amount that a provider will pay on a particular policy. Many insurance companies have a lifetime cap of $1 million, which can be easily attained in cases of prolonged medical treatment and care.

Insurance Company Name – Name of the company that your claim will be sent to.

Insured Group Name – Name of the group or insurance plan that insures you, usually an employer.

Insured Group Number – A number that your insurance company uses to identify the group under which you are insured.

Insured’s Name (Beneficiary) – The name of the insured person.

Intensive Care – Medical or surgical care unit in a hospital that provides care for patients who need more care than a general medical or surgical unit can give.

Internal Control Number (ICN) – A number assigned to your bill by your insurance company or their agent.

International Classification of Diseases, 9th Edition (ICD-9-CM) – A coding system used to describe what treatment or services your doctor gave to you.

IV Therapy – Treatment provided by giving intravenous solutions or drugs.

Labor and Delivery Room – A unit of a hospital where babies are born.

Laboratory – Charges for blood tests and tests on body tissue samples, such as biopsies.

Lifetime Reserve Days (Medicare) – Under Medicare, you have a lifetime reserve of 60 more days of inpatient services after you use the first 90 benefit days. You must pay a fixed amount for each day of service.

Long-Term Care – Care received in a nursing home. Medicare does not pay for long-term care unless you need skilled nursing or special rehabilitation.

Mailer/Summary of Account – A monthly summary of services (and charges?) mailed to the person who pays the bill.

Managed Care – An insurance plan that requires patients to see doctors and hospitals that have a contract with the managed care company, except in the case of medical emergencies or urgently needed care if you are out of the plan’s service area.

Medicaid – A state administered, federal and state funded insurance plan for low-income people who have limited or no insurance.

Medical Record Number – The number assigned by your doctor or hospital that identifies your individual medical record.

Medical/Surgical Supplies – Special supplies, such as materials used to repair a wound or instruments used for your care.

Medicare – A health insurance program for people age 65 and older. Medicare covers some people under age 65 who have disabilities or end-stage renal disease (ESRD).

Medicare + Choice – A Medicare HMO insurance plan that pays for preventive and other healthcare from designated doctors and hospitals.

Medicare Approved – Medical services for which Medicare normally pays.

Medicare Assignment – Doctors and hospitals who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.

Medicare Number – Every person covered under Medicare is assigned a number and issued a card for identification to providers.

Medicare Paid – The amount of your bill that Medicare paid.

Medicare Paid Provider – The amount of your bill that Medicare paid to your doctor or hospital.

Medicare Part A – Usually referred to as Hospital Insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs.

Medicare Part B – Helps pay for doctor services, outpatient care, and other medical services not paid for by Medicare Part A.

Medicare Summary Notice (MSN) – The notice you receive from Medicare after getting services from your doctor or hospital. It tells you what was billed to Medicare, Medicare’s approved payment, the amount Medicare paid, and what you have to pay. Also called an Explanation of Medicare Benefits (EOMB).

Medigap – Medicare Supplement Insurance that pays for some services not covered by Medicare A or B, including deductible and co-insurance amounts.

MRI – A type of X-ray; magnetic resonance brain or body images, usually done in a hospital’s x-ray department.

Network – A group of doctors, hospitals, pharmacies, and other health care experts hired by a health plan to take care of its members.

Non-Covered Charges – Charges for medical services denied or excluded by your insurance. You may be billed for these charges.

Non-Participating Provider – A doctor, hospital, or other healthcare provider that is not part of an insurance plan’s doctor or hospital network.

Nursery – Nursing care charges for newborn babies.

Observation – Type of service used by doctors and hospitals to decide whether you need inpatient hospital care or whether you can recover at home or in an outpatient area. Usually charged by the hour.

Oncology – Charges for treating cancer and related diseases.

Operating Room – A hospital or clinic area where surgeries are done.

Other Room and Board – Any extra charges that cannot be included in routine room and board charges.

Out-of-Network Provider – A doctor or other healthcare provider who is not part of an insurance plan’s doctor or hospital network. Same as non-participating provider.

Out-of-Pocket Costs – Costs you must pay because Medicare or other insurance does not cover them.

Outpatient (OP) – Patient who does not need to stay overnight in a hospital. Outpatient services include lab tests, x-rays, and some surgeries.

Outpatient Service – A service you receive in one day at a hospital or clinic without staying overnight.

Over-the-Counter Drug – Drugs not needing a prescription that you buy at a pharmacy or drug store.

Paid to Provider – Amount the insurance company pays your medical provider.

Paid to You – Amount the insurance company pays you or your guarantor.

Participating Provider – A doctor or hospital that agrees to accept your insurance payment for covered services as payment in full, minus your deductibles, co-pays and co-insurance amounts.

Patient Amount Due – The amount charged by your doctor or hospital that you have to pay.

Patient Type – A way to classify patients–outpatient, inpatient, etc.

Pay This Amount – How much of your bill you have to pay.

Per Diem – Charged/Paid by the day.

Pharmacy Charges – Cost of drugs given under a pharmacist’s direction.

Physical Therapy – Treatment of diseases or injuries by exercise, heat, light, and/or massage.

Physician – Person licensed to practice medicine.

Physician Extenders – Also called mid-level service providers. Physician extenders include licensed nurse practitioners and/or licensed physician assistants. They coordinate patient care under a doctor’s supervision.

Physician Office – Your doctor’s office.

Physician Practice – A group of doctors, nurses, and physician assistants who work together.

Physician Practice Management – Non-physician staff hired to manage the business aspects of a physician practice. These staff include billing staff, medical records staff, receptionists, lab and X-ray technicians, human resources staff, and accounting staff.

Point-of-Service Plan (POS) – An insurance plan that allows you to choose doctors and hospitals without having to first get a referral from your primary care doctor.

Policy Number – A number that your insurance company gives you to identify your contract.

Pre-Admission Approval or Certification – An agreement by your insurance company to pay for your medical treatment. Doctors and hospitals ask your insurance company for this approval before providing your medical treatment.

Pre-Existing Condition – A health condition or medical problem that you already have before you sign up to receive insurance. Some health insurers may not pay for health conditions you already have.

Pre-payments – Money you pay before getting medical care; also referred to as pre-admission deposits.

Prevailing Charge – A billing charge that is commonly made by doctors in a specific region or community. Your insurance company determines this charge.

Primary Care Network (PCN) – A group of doctors serving as primary care doctors.

Primary Care Physician (PCP) – A doctor whose practice is devoted to internal medicine, family/general practice, or pediatrics. Some insurance companies consider Obstetrician/gynecologists primary care physicians.

Primary Insurance Company – The insurance company responsible for paying your claim first. If you have another insurance company, it is referred to as the Secondary Insurance Company.

Private Room (Deluxe) – A more expensive hospital room than those available to other patients. You may have to pay extra for this type of room if it is not a medical necessity.

Procedure Code (CPT Code) – A code given to medical and surgical procedures and treatments.

Prospective Payment System (PPS) – A Medicare system that pays hospitals a set amount for covered diagnostic or treatment services.

Provider – A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.

Provider Contract Discount – A part of your bill that your doctor or hospital must write off (not charge you) because of billing agreements with your insurance company.

Provider Name, Address, and Phone # – Name and address of the doctor or hospital submitting your bill.

Psychiatric/Psychological Treatments – Nursing care and other services for emotionally disturbed patients, including patients admitted for inpatient care and those admitted for outpatient treatment.

Radiology – X-rays used to identify and diagnose medical problems.

Reasonable and Customary (R & C) – Billing charges that insurers believe are appropriate for services throughout a region or community. 

Recovery Room – A special room where you are taken after surgery to recover before being sent home or to your hospital room.

Referral – Approval needed for care beyond that provided by your primary care doctor or hospital. For example, managed care plans usually require referrals from your primary care doctor to see specialists or for special procedures.

Referring Physician – A physician who sends a patient to another doctor for specialty care or services.

Release of Information – A signed statement from patients or guarantors that allows doctors and hospitals to release medical information so that insurance companies can pay claims.

Renal Dialysis – Removal of wastes from the blood. Normally the kidneys would remove these wastes if they were functioning properly.

Respiratory Therapy – Giving oxygen and drugs through breathing, as well as other therapies that measure inhaled and exhaled gases and blood samples.

Responsible Party – The person(s) responsible for paying your hospital bill–usually referred to as the guarantor.

Revenue Code – A billing code used to name a specific room, service (X-ray, laboratory), or billing sum.

Room and Board Private – Routine charges for a room with one bed.

Room and Board Semi-Private – Routine charges for a room with two beds.

Same-Day Surgery – Outpatient surgery.

Secondary Insurance – Extra insurance that may pay some charges not paid by your primary insurance company. Whether payment is made depends on your insurance benefits, your coverage, and your benefit coordination.

Service Area – Geographic area where your insurance plan enrolls members. In an HMO, it is also the area served by your doctor network and hospitals.

Service Begin Date – The date your medical services or treatment began.

Service Code – A code describing medical services you received.

Service End Date – The date your medical services or treatment ended.

Skilled Nursing Facility – An inpatient facility in which patients who do not need acute care are given nursing care or other therapy.

Source of Admission – The source of your admission—referral, transfer, emergency room, etc.

Specialist – A doctor who specializes in treating certain parts of the body or specific medical conditions. For example, cardiologists only treat patients with heart problems.

Statement Covers Period – The date your services or treatment begin and end.

Submitter ID – Identification number (ID) that identifies doctors and hospitals who bill by computers. Doctors and hospitals get an ID from each insurance company to whom they send claims using the computer.

Subscriber – A person who enrolls in a health care plan and agrees to pay for premiums, co-payments and deductibles that are part of the plan.

Supplemental Insurance Company – An additional insurance policy that handles claims for deductible and co-insurance reimbursement.

Swing Bed – Bed for a patient who receives skilled nursing care in a non-skilled nursing facility. 

Total Charges – Total cost of your medical services.

Type of Admission – The reason for your admission, such as emergency, urgent, elective, etc.

Type of Bill – A bill that shows what type of care is being billed, such as hospital inpatient, hospital outpatient, skilled nursing care, etc.

UB92 Billing Form – A form used by hospitals to file insurance claims for medical services.

Units of Service – Measures of medical services, such as the number of hospital days, miles, pints of blood, kidney dialysis treatments, etc.

Utilization Review (UR) – Hospital staff who work with doctors to determine whether you can get care at a lower cost or as an outpatient.

You May be Billed – A phrase used by your insurance company informing you that your doctor or hospital may bill some charges directly to you.

The Medical Billing Industry

February 21, 2011

I get asked frequently:  How did you get into Medical Billing?  Can I get started without any experience?  Is it true you can make lots of money at this?  Do you think it is something I can do?  Is it true you can do this from home?  If these are questions you have had, I hope this article will help answer them for you.

As of the date of this article, I have 15 years experience in the Medical Billing industry and I answer the question about how I got into the field here.  You can get started without experience, just as I did, but without experience you will have a hard time convincing a physician or practice manager that you know what you are talking about and that they should entrust you with such a substantial part of an impact to their practice, remember you are dealing with the cash-flow of their business.  A physician is going to want to see that you have a history of experience, knowledge pertinent to their specialty and an ability to collect on their claims.  I would recommend anyone wanting to get into the Medical Billing industry obtain a position working in the medical field directly with someone who has this knowledge and begin learning the industry in a hands on method.  This process is critical for success as to learn all this on your own without anyone that has the expertise needed would make a challenging career even more challenging, and a lot of mistakes would be made by trial and error that can be avoided!  

The health insurance industry and medical billing industry go hand-in-hand and are ever-changing. Federal and State regulations are continuously changing and unless you are prepared to continue education and stay up on the rules you will only be frustrated by the results of your efforts.  This is not a field you learn the basics and don’t have to continue to learn the industry.  Education and knowledge are one of the main keys, if you are willing to invest the time in learning the industry, understand that there are very strict regulations, have a growing commitment to continued education, have an aptitude for attention to detail, comprehend the requirements and need for accuracy, know you will need to fight to get things resolved and not sit back and wait for the process to happen, then you will be an excellent Medical Biller and you can be very successful. In order to be successful in an overwhelmed industry with a greater need then was there say 10 years ago for medical billing, you have to educate providers on all the benefits of outsourcing on top of marketing your education and/or experience.  The term medical billing is very generic because the title doesn’t convey all that is involved.  To be an excellent Medical Biller you will have to have strong knowledge of financial concepts and accounting principles, be well-organized, detail oriented, efficient, accurate, strong analytical skills, ability to multi-task, willing to fight for your rights, understand all rules and regulations (including but not limited to federal, state, provider, insurance carrier, etc), understand the importance of follow-up and promptness, ability to explain to both the physician and the patient every aspect regarding their benefits and the way a claim was processed, etc.  The process of medical billing involves everything from benefit verification to claims follow-up, appeals, payment posting, recoupments, refunds, overpayments, patient billing, providing your client with precise and accurate statistical reports on the health of their practice, etc.  Basically you are following every claim from beginning to end to create a zero balance, this sounds easier said than done. Let’s look at the various elements of what you need to provide your client with these services:

  • Understand the CPT, HCPCS, and ICD9 Rules and Regulations
  • Understand and identify Modifiers and their various uses
  • Understand the importance of verifying and understanding patient’s benefits
  • Understand the importance of obtaining and understanding managed care authorizations and coverage limitations
  • Understand the various types of insurance plans available and being able to differentiate each plan and how they are constructed (HMO, PPO, Indemnity, POS, Workers Compensation)
  • Understand the insurance contracts for you provider
  • Understanding government payers as well as federal and state regulations
  • Understanding the CMS HCFA1500 form and UB92 form
  • Understand each element of the electronic claims filing process
  • Understanding the HIPAA Regulations (Health Insurance Portability and Accountability Act) and adhering to the rules
  • Understanding the importance of compliance as well as policies and procedures
  • Understand the importance of continued education, both on-line or in-class (seminars, association memberships, insurance bulletins, etc)

Many advertisers market Medical Billing as someone who just files insurance claims and makes a lot of money doing so from home.  Yes, you can do medical billing from home, but it isn’t something you just push a button and it happens, it does take a skilled person to be involved in the process, it is not 100% automated.  Can money be made at Medical Billing?  Yes.  Is it lucrative?  No.  Just like any other industry out there, greater money is made by hard work and effort, it is not a get rich quick scheme.  If you want to make good money, you are going to have to work very hard to do so.  It is a rewarding industry if you put the time and effort into learning it.

Medical Billing vs Medical Coding

February 14, 2011

Medical Billing is the practice of submitting reimbursement claims to Insurance companies (e.g. Blue Cross Blue Shield) or the United States government (e.g. Medicare or Medicaid), in order to receive payment for services provided to a patient by a doctor.

Medical Coding is the practice of putting the procedure codes (CPT or HCPCS Code) and diagnosis codes (ICD9 Codes) in a format to be paid by the insurance company.   This information is provided by the office visit notes and then reviewed for entering and transmission.

The terms Medical Coding and Medical Billing are often used synonymously, however, medical coding must be performed by a medical coder before the medical billing reimbursement claim can be submitted.  Medical Billing is a subspecialty of Medical Coding.

Medical Billing in the physician office is typically performed by a clerk through medical billing software. After a physician sees and diagnoses the patient, and performs the necessary procedure, the physician then makes his/her notes of the diagnosis and procedure and gives those notes to the Medical Coder. The physician’s diagnosis and procedure is then properly coded before the medical billing reimbursement claim can be submitted. After the medical coding is completed, the medical billing claim can be completed and submitted for reimbursement.

Although there are programs that offer Medical Billing training by itself, if you are going to consider a course, you should consider a program that combines both billing and coding in one training program, since Medical Coding is the first step in the medical billing process.

What exactly is Medical Billing?

February 7, 2011

I have been in the Medical Billing industry for 15 years and I get asked this question frequently by people I network with and by my friends in curiosity:  Just what exactly is Medical Billing?  This article will give you a general understanding of what it is and how the processes is done.  

Medical Billing is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. Basically the medical billing process is an interaction between the health care provider and the insurance company (aka the payer).

Prior to actually performing medical services to the patient and/or billing services to an insurance company, the health care provider checks the eligibility & benefits of the patient for the intended services with the patient’s insurance company.  This process is called an Eligibility & Benefits Inquiry.  The information obtained discloses to the provider of service the benefits the patient has in regards to the co-payment, deductible, co-insurance, out-of-pocket expense, exclusions & limitations, along with pre-existing information.  These benefits should be explained to the patient before services are rendered in case the patient has any questions and to avoid issues later.  The provider will render medical services to the patient and the findings will be reported in the patient record which contains highly personal information, including the nature of the illness, examination details, medication lists, diagnoses, and suggested treatment.  The extent of the physical examination, the complexity of the medical decision-making and the background information (history) obtained from the patient are evaluated to determine the correct level of service that will be used to bill the insurance. The level of service, once determined by the qualified staff is then translated into a standardized five digit procedure code drawn from the CPT (Current Procedural Terminology) database. The diagnosis is translated into a numerical code as well, drawn from a similar standardized ICD-9 (soon to be ICD-10) database.  Once the procedure and diagnosis codes are determined, the medical biller will transmit the data electronically (or via paper if specified by the payer) on a claim form (either a HCFA1500 or UB92; both known as a claim forms – one for out-patient providers and one for in-patient providers) showing the patient’s demographic information, insurance policy, provider of service, CPT code, ICD-9 code, fees for services rendered, payment made at the time of service, along with other data required for transmission and processing for payment.  The insurance company (payer) then processes the claim(s) according to several factors.  This process is done by medical claims examiners or medical claims adjusters, and the claims are evaluated for their validity for payment using rubrics (a type of procedure) for patient eligibility, provider credentials, clean claim requirements, and medical necessity.  If the provider is an In-Network provider, the approved claims are reimbursed at the negotiated contract rate.  If the provider is an Out-of-Network provider, the claims are processed according to the patient’s benefits.  Rejected and failed electronic claim notices are sent to provider for review.  The information is then deciphered, reconciled, required corrections are made (if applicable) and the claim is resubmitted to the payer (if applicable).  Once the provider receives the EOB (Explanation of Benefits), RA (Remittance Advice) or R&S (Remittance and Status), the claim is then processed and the data reconciled and the patient will be balance billed for any additional amount due.  However, if the claim was paid incorrectly by the payer or denied by an insurance company inaccurately, it must be appealed.  The goal of the provider is to have limited rejections, denials, and errors made on behalf of either party (the provider and/or payer).   This exchange of claims and rejections may be repeated multiple times until a claim is paid in full, the balance is applied to the patient’s responsibility, or the provider relents and accepts an incomplete reimbursement due to contract guidelines or exhaustion of appeal rights.   The medical billing process can take anywhere from several days to several months to complete, and require several iterations before a resolution is reached. 

This medical billing process outlined here is generally the same for most insurance companies, whether they are private companies or government-owned, however there are policy guidelines and regulations that govern the benefits, change the way claims are paid and processes are done.  The health care provider or medical biller must have complete knowledge of different insurance plans, federal laws, state laws, and insurance regulations that preside over them in order to be able to process the claim and receive maximum reimbursement.   When providers agree to accept an insurance company’s plan, the contractual agreement includes many details including fee schedules which dictate what the insurance company will pay the provider for covered procedures and other rules such as timely filing guidelines and prompt pay requirements.  

Medical billers are encouraged, but not required by law to become certified. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field, but they do not teach you the concepts to actually be a medical biller or provide a medical billing service. 

In many cases, particularly as a practice grows beyond its initial capacity to cope with its own paperwork, providers outsource their medical billing process to a third-party known as a Medical Billing Service. These entities reduce the burden of paperwork for medical staff and recoup lost efficiencies caused by workload saturation, lack of experience at claim resolution and insurance guidelines, reduction in payroll expenses of the practice (typically the Medical Billing Service is paid a percentage of collections not just earning an hourly wage regardless of physician’s reimbursement), along with an overall greater efficiency hence paving the way for further practice growth.

My Story: how I got into Medical Billing

January 24, 2011

My name is Misty Gilbert and I have been in the medical field for 15 years.  My experience in the medical billing industry comes from working in doctor’s offices and with my client’s. 

I took my first job with a Dermatology office in California, March 1996.  I was hired as a part-time File Clerk and only worked part-time, the first day!   I took on any task they gave me from the mountain of filling in the sample closet to typing surgical reports, preparing pathology slides for review, verifying benefits, answering the telephone and booking patient appointments, etc.  When the day came that one of the physician’s medical billers quit, the physician I was working for asked me what I thought about his decision to have me assist the other biller, I jumped at the opportunity.  I took lots of notes from Fawn and I quickly caught on to the way things needed to be done.  I enjoyed the work and was really grateful to be learning a “skill”, beyond just filling in and helping where ever they needed me in the office.  The day came when I received an offer from a Cardiologists office two doors down to work for them doing Medical Billing at a dollar an hour more.  You might not think that was much money, but to me, it was!  I jumped at the opportunity, besides it had Health Insurance Benefits too, something I didn’t have at the Dermatologists office.  My employer wasn’t happy to be loosing me, but he didn’t wish to give me a pay raise and he didn’t offer health insurance benefits.  When I left California to move to Texas in September 1997, I took a job as a Medical Receptionist in an OBGYN’s office making $2.00 an hour more than I had been in California as a Medical Biller.  I was really impressed.  I knew at some point I would want to get back into doing medical billing, but for the time being, I was happy with the pay increase. I eventually moved on from that job to a position in Accounting and was promoted internally to a Collections position where I learned lots about the regulations set forth pertaining to that.  The job was very stressful, but it allowed me to have even more experience that furthered my medical billing career as I worked at debt collection and payment plans pretty much all day every day.  The started looking for a better opportunity and the next position I took is what led me back into Medical Billing.  The years of experience in the medical industry and various positions I had working with different employers since 1996 has only increased my skills and expertise in many specialty fields, bring me to where I am today. 

I have experience in the following fields:  Dermatology, Cardiology, OBGYN, 3rd Party Pharmacy Claims Processor (for Tricare beneficiaries), Home Healthcare, Pediatrics, Family Practice, Internal Medicine, Orthopedic, Ophthalmology/Ophthalmic Plastic Surgery, and Optometry.  I have worked as a File Clerk, Receptionist, Data Entry Clerk, Medical Biller, Collections Representative, Billing Analyst & Collections Manager, Billing Manager, Office Manager and Accounting Manager. 

My experience as a medical biller and office manager have given me the opportunity to have insight into assisting medical practices increase their cash flow and maximize reimbursements.  I started my own Medical Billing Agency, Medical Account Solutions, June 2004 when I felt I could offer more than the typical medical billing agency does in today’s market.  It is my goal to help physicians thrive at doing what they do best.  They need staff that is organized, focused and efficient and our goal is to help them accomplish this.  Medical Account Solutions offers al-cart or full service medical billing services, consulting and training.  I worked solo for the first 4 years and hired my first part-time employee in 2008 and my second later that year.  I am passionate about what I do and enjoy helping business find solutions to their problems.  Our team provides expertise and accuracy and you get a personalized hands-on approach with the services we offer. 

My long-term goal for the business is to offer classes and training to physician’s as they complete their residency program.  They are not taught basic business practices, the medical billing rules and regulations, what is required to start a medical practice, what aspects are involved, or the length of time the credentialing processes take.  Physician’s graduate expecting that as soon as they get their practice setup and start seeing patients that they will be making money.  I want to be a resource and assist them with better tools to start out their medical practice in a different position then they typically do.

This is my story on how I got into doing Medical Billing.  Do you have a story to share?