Billing Training Complete

Medical Billing Training Page 1 of 207

Contents

1. About ….

2. A Study on IT Enabled Services

3. A Study on Medical Billing


4. Medical Billing - Introduction

Overview of Insurance ScenarioConcept of Medical BillingParties in Medical BillingRole of a Medical Billing CompanyTypes of Payers

5. Medical Coding

IntroductionDiagnosis: ICD-9 CodesProcedures: CPT-4, HCPCS & Other Coding SystemsRelative Value UnitsModifiersFacilityPlace of ServiceType of Service

6. Insurance Carriers – Medicare

Introduction

Medicare – An operations studyEligibility & EntitlementMedicare DeductiblesMedicare Co-insuranceThe Medicare ID CardMedigap CoverageParticipation & Non-participationMedicare Fee Schedule – The Resource Based

Relative Value Scale (RBRVS)Medicare as a Secondary Payer (MSP)Medicare Appeals Process

7. Insurance Carriers - Medicaid

Medicaid – An operations studyEligibilityClaims Submission & Payment

8. Insurance Carriers – Blue Cross Blue Shield


Blue Cross Blue Shield – An operations studyIntroductionBCBS ID CardPlans of BCBSCo-ordination of Benefits (COB)Methods of PaymentClaims submission

9. Insurance Carriers – Managed Care and Other Plans

Managed Care – An operations studyIntroduction and DefinitionObjectives of Managed CareTypes of Managed Care PlansMethods of Payment

Other Government & Private PlansOther Government PlansCHAMPUS CHAMPVARAILROAD MEDICAREWORKERS COMPENSATION

Other Private Plans

10. Enrollment Process

Provider EnrollmentEDI Enrollment

11. Patient Enrollment and Insurance Adjudication

Patient EnrollmentInsurance Adjudication

12. Medical Billing Process – Flow Chart and Introduction

13. Patient Demographics Entry


Basic Collection of Information & DocumentationPatient Demographic Entry

14. Charge Entry

Basic Collection of Information & DocumentationCoding of procedures and diagnosisPre-codingCharge EntryLocum Tenens & Reciprocal Billing

15. Claims Audit

IntroductionFunctions

16. Claims Generation and Transmission

IntroductionPaper ClaimsElectronic TransmissionReports to be maintained

17. Patient Bills Generation

18. Cash Transaction

IntroductionExplanation of BenefitsCash Posting

19. Claims Denials and Regular Mail Receipts

IntroductionRegular Mail EntryAction on Regular Mails

20. Records Keeping

21. Claims Analysis

IntroductionAnalysis


22. Insurance Calling

IntroductionFunctions

23. Patient Calling

Introduction Functions

24. Budget Payment and Collection Agency

Patients in BudgetPatients in Collections

25. Financials and Month End Reports

Daily ReportsMonthly ReportsCommon terms used in financialsExpectation Reports

26. Duties and Responsibilities

Charge Entry PersonCash PosterRegular Mail PersonAR AnalystAR Manager

27. Performance Appraisal

28. Importance of Meetings

29. HIPAA Complaince

30. Code of Conduct


A Study on IT Enabled Services

India's irresistible and sustainable value proposition

By outsourcing IT enabled services requirements to India, large overseas companies, including increasing number of Fortune 500 companies and existing overseas service providers, are not only achieving significant benefits in cost, quality and time but also creating platforms for building new businesses. Overall, these benefits are due to the advantages offered by relevant skill-surplus economies. India offers the case of best value proposition for all IT enabled services.

India's value proposition is already leading IT enabled services hubs such as Ireland and Singapore to back-end their operations in India, since skilled labor is becoming an increasingly scarce resource in these countries. To top it up, telecom infrastructure is increasingly becoming competitive in India. Coupled with active support of state, India is offering hard to beat proposition to emerge as a "Preferred Global Hub."

Seizing the opportunity, several companies in the financial service sector, for example, have saved at least 50-60 percent of their process costs. The process redesign that comes with, out location also provides additional cost savings and consolidation of operations.

A comparison amongst some countries in Asia Pacific based on these factors highlights the following:

(Ratings are on a scale of 1 to 3, with 1 being the lowest and 3 the highest.)


IT enabled service centres in India are able to deliver superior quality because of specialisation and scale benefits. India already has a large and rapidly growing number of IT enabled services' providers collectively covering a wide range of services with different levels of complexity and value adds. Yet another compelling rationale for IT enabled services is that it allows companies to capitalise on time zone differences and to provide round-the-clock services, every day of the week on (24 x 7) model. For example, doctors in the US can have transcribed records of their notes at the start of the next day by sending them to medical transcription services in India who will start work at the end of their working day in the US.

Finally, companies can discover new business opportunities in the skills they learn from operating IT enabled services. GE Capital, one of the largest IT enabled services' operation is now planning to extend its services beyond financial services to other GE group companies as well as to external customers. It aims to expand its IT enabled services' operations in India to over 10,000 employees.

Further Multinational Firms like World Bank, American Express, British Airways, Swiss Air, Singapore Airlines, US hospitals and 3 COM have already started outsourcing their work to India.India and Ireland have emerged as particularly attractive locations for IT Enabled Services.

These advantages are supported by the significant number of entrepreneurship opportunities dotting India's technology landscape as well as increasing value creation opportunities for venture capitalists through this sector.


A Study on Medical Billing

IT enabled services or remote services involve a broad range of information technology based decision-making and information delivery services. The recent spurt of growth in IT Enabled services has been mainly due to cost effective telecommunication links and the ability to handle these projects on a cross border basis.

Tracobi offers Medical Billing services thru IT Enabled Services for US clients.

Can Medical Billing Companies in the US have their back Offices in India, Is it possible?

Yes, the latest revolution in information technology and telecommunications has shrunk the geographical boundaries and has made it possible. The new technology has come as a boom for the medical billing companies in the U.S. to outsource their voluminous and labor intensive Medical Billing Services to India. How does it work?

How does it work?


Billing Companyin USA (You)

Your Back Office in Hyderabad, India

Hospital / Doctor

A Hospital / Doctor will send the data's to your office and all you have to do is to scan them to the FTP site. Tracobi will do the rest.

Tracobi is proficient in the understanding of the most current insurance plans including managed care, HMOs and indemnity health plans as well as Medicare, Medicaid, Personal Injury and Workers Compensation.

Tracobi currently provides a wide range of customizable services, most of which are standard with most billing companies and We feel our special value comes from the emphasis we place on electronic billing and the control of accounts receivable balances via frequent and thorough follow-up of our client's accounts.


Insurance Companies

Medical Billing – Scenario & Overview

Comparative Study - Scenario of Healthcare Insurance in United States and India

The Healthcare Industry in United States operates in an altogether different way from the scenario prevailing in India. In India, the physicians accept cash for the entire amount due from the patients directly after the services are rendered. But in United States, the costs for any Medical service is very high compared to any other country in the world and hence a common man will not be able to afford the entire costs of his / her / family medical expenses. Here is where the insurance comes into picture. The Healthcare Industry joins hands with the Insurance sector to form the concept called Health Insurance.

The citizen of the United States take healthcare policies with the insurance companies paying a premium and receiving healthcare coverage in return. There are different plans in policies taken and each will define its own scope and limitations. Insurance companies take the responsibility of all the financial risks of the policy in relation to the medical services received by the insured for himself or his dependents during the tenure of the policy and are hence referred to as CARRIERS. The scope of the policies will be limited to a given set of benefits and subject to certain conditions. Only if these criteria are met, the services rendered / received will be reimbursed / paid by the CARRIERS to the physicians / patients.

Concept of Medical Billing

Unlike India, the responsibility of the physician does not end with giving treatment alone. To get paid / reimbursed for the services rendered, the physician, after rendering the treatment to the


patient has to submit a claim in a specified format called as CMS-1500 to the Insurance company with which the patient has got his / her coverage. Upon receipt of the claim the Insurance company will review it and then reimburse / pay the physicians. Almost all of the patients will have health insurance policy and the details of it will be provided to the physician before the treatment is rendered. The process of submitting claims and getting paid is lengthy and tedious. It also involves a lot of rules and regulations formed by the HealthCare Financing Administration to be followed. These rules and regulations differ from state to state and are very rigid and complicated. The physician needs to adhere to all these during the process of submission of the claims.

On most of the occasions the physicians would not be able to divert their entire attention to this process of submission of claims, but will have to do it for getting paid and running their business. The concept of Medical Billing comes in here handy to help the physicians concentrate more on their patients and practice, rather than on submission of claims and getting reimbursed. The physician can entrust the activities of preparation of claims, submission of it and getting reimbursed / paid to billing companies. In other words, Billing companies act as a Bridge between the Insurance companies and the physicians.

Parties in Medical Billing

The entire process of Medical Billing revolves around three main players:

1. PATIENT / INSURED 2. PHYSICIAN / PROVIDER and 3. INSURANCE COMPANY / CARRIER.

Patient / insured is the person who has an ailment and gets his ailment cured by Physician / provider and then reimburses / pays them through his Healthcare Insurance Company / Carrier gets paid back by the patient / insured thru premiums.

All these parties interact with each other and form a striking unison.


Role of a Medical Billing Company

Though a Medical billing company is appointed by the Physicians / Providers, it acts as a bridge between the Insurance companies and Physicians. The prime aim of any billing company should be to keep everybody involved in the process non-obligatory to each other in terms of money without violating the boundaries of the others. If a Billing Company can do it, it is what a Provider wants, a Carrier and a Patient would want.

They should clearly spell out their duties and responsibilities with limitations on their boundaries in their agreement with the Physician. The agreement should contain the process to be adopted by the Billing Company in carrying out the objective of the physician. The agreement should also spell out suggestions and modus operandi on an ambiguous situation.

Types of Payers

Payers are nothing but the Insurance companies / Carriers. They are referred to as payers since they play an important role in the payment flow of the entire process. The Carriers can be broadly classified into two - Government Plans and Private Plans. Governmental Plans has the following within its fold: Medicare, Medicaid, Railroad Medicare, CHAMPUS and workers compensation. Private plans are operated by private insurance companies, which act as the payer. Examples of private plans are Blue Cross & Blue Shield, Aetna USHC, Cigna, Prudential Healthcare etc. The Private payer plans are further subdivided into various plans like traditional indemnity benefit plans; self-insured plans and managed care plans etc.


Medical Coding

Scenario & Overview

Coding is an important process by which we represent / report the description of treatments and diagnosis in a numerical format. This representation in numerical format enables us to co-relate the description with a particular numerical value.

This numerical value ranges from 00100 to 99999 for treatment codes and it is further sub-divided into each region of the human body. (E.g.- 99213 – represents / reports the treatment for Established Physician Consultation - level 3). For diagnoses representation the value ranges from 001 to 999.9. The way to


identify whether the numerical representation is for a treatment or a diagnosis can be done by a simple method. If the # of digits is FIVE without any decimal it means that the code represents a treatment. For diagnosis the numerical representation will be in 3 digits with or without decimals. It helps both the providers and carriers to identify and co-relate the description with a particular numerical value. The reimbursement process for the same would also be easy since understanding of the description by the claims processor does not become a problem and inordinate delays in reimbursement would be completely avoided. US Department of Health has hence brought in numerical codes to represent the description in the claim forms making it easy and simpler both for the provider as well as for the claims processor.

Diagnosis: ICD-9-CM Codes

The ICD or International Classification of Diseases (ICD-9-CM - International Classification of Diseases, Ninth Revision, Clinical Modification) is an arrangement of the numerical representation of the description of diagnoses in an orderly fashion ranging from 001 to 999.9. This representation of codes was published by W H O (World Health Organization) and recognized by the US Department of Health and Human Services.

ICD-9-CM codes range between 3, 4 or 5 digit numerical codes from 001 to 999.9. The first three-digits represent the parent code of the disease. The supplemental fourth & fifth digits will add specificity to the parent code. We are supposed to use the most appropriate and specific diagnosis code when we represent a description in a claim.

Apart from these numerical codes there are also V-codes and E-codes. These codes are called as HCFA Common Procedure Coding System codes. V-Codes represent supplementary factors influencing health status and contact with health services (V01-V82) and E-Codes are supplementary classification of external causes of injury and poisoning (E800-E999).

Procedures: CPT-4, HCPCS & Other Coding Systems


The CPT-4 or Current Procedural Terminology is the numeric representation of the procedures/ treatment rendered to the patients. This coding system was developed by American Medical Association and has been acknowledged by the Health Care Financing Administration. As said earlier these are five digit numeric codes starting from 10000-99999. The entire set of codes from 10000-99999 is further subdivided into various ranges of codes covering various sites of the body and specialty of treatment such as Integumentary, Musculoskeletal, Respiratory, Digestive, Nuclear Medicine, E & M etc.

HCPCS Codes - HCFA Common Procedure Coding System are codes designed by the Health Care Financing Administration (HCFA). These are also five digit codes with an alphanumeric representation. Only certain limited carriers accept these codes for reimbursement. These codes act as a supplementary to CPT-4 and mainly concentrate on the aspects not covered in CPT.

The ASA Codes were developed keeping in view the requirements of the Anesthesia aspect of coding by the American Society of Anesthesiologists. The codes range from 00100 through 01999. Federal carriers accept these codes and almost Medicare carriers of all the states and some Medicaid carriers accept these codes for reimbursement.

Relative Value Units

The regularization of the reimbursements to the commercial carriers is the main reason for which the RVU or Relative Value Units were assigned to CPT codes for reimbursement by the Omnibus Budget Reconciliation Act of 1989 (OBRA, later amended in 1990). The calculation of the RVU for each service is based on three basic components involved in a physician’s service - (1) Work; (2) Practice Expenses; and (3) Cost of Malpractice insurance. Relative Value Units (RVUs) reflect the resources involved in furnishing the three components of a physician’s service:

Modifiers


Modifiers, as the name suggests, modify the nature of a service and add a degree of accuracy to the reporting of the treatment. For e. g modifier LT refers to Left side of the human body and hence a cataract surgery with a LT modifier would mean that the surgery has been performed on the left eye. Adding this clarity to the reporting of the treatment is what modifier does. It helps to a great extent not only in reporting the treatment to the most accurate level but also in calculating and deciding the further course of the treatment. The following illustrates the various scenarios where we have to use a modifier to clear ambiguity in reporting.

A service or procedure has both a professional and technical component.

A service or procedure was performed by more than one physician and/or in more than one location.

A service or procedure has been increased or reduced. Only part of a service was performed. An adjunctive service was performed. A bilateral procedure was performed. A service or procedure was provided more than once. Unusual events occurred.

The most commonly used modifiers are

Professional Component 26Technical Component 76Bilateral Procedure 50Right side of body RTLeft side of body LTDistinct Procedural Service 59

Facility / Location

Facility / Location is where the doctor renders his service / s to the patient. It can be an Office, a Hospital, a skilled nursing facility, a clinic or even the patient’s home. This has to be reported with the appropriate Place of Service code to identify the location.


Place of Service

The numeric representation of the description of the facility type is called as Place of Service. This refers to the facility type in which the services are rendered. These numbers are two digit numbers. A few of the Places of Service used are

Inpatient - 21 Outpatient - 22 Office Visit - 11 Emergency Room - 23Ambulatory Surgical Center – 24

Type of Service

The numeric representation of the treatment type is called as Type of Service. This refers to the specialty in which the services are rendered. These are single digit and two digit numbers. A few of the types of services used are

Anesthesia - 7Radiology – 4Medical Services - 1


Insurance Carriers – Medicare

Introduction

As discussed earlier, insurance carriers are broadly classified into two: Government & Private. Government carriers also called as Federal carriers are mainly Medicare & Medicaid. Private carriers also called as Nonfederal carriers are mainly Blue Cross Blue Shield, Commercial and Managed Care carriers. Let us discuss them in detail in this section.

Medicare – An operations study

Medicare is a federal plan which is an entitlement program administered by HCFA (Health Care Financing Administration) for patients over age 65 years, certain disabled individuals, and those with end-stage renal disease.

Under the Social Security Act, two insurance programs were established in 1965: PART-A (hospital insurance) and PART B (voluntary medical insurance). Both Part-A and Part-B are available to persons entitled to Medicare benefits.

Eligibility and Entitlement

The following category of persons are entitled to Medicare benefits:

a) Individuals who are 65 years and above and have paid FICA (Federal Insurance Contributions Act) taxes or Railroad Retirement taxes for at least 40 calendar quarters (10 years).

b) Adults disabled before age 18 and Parents are either disabled or eligible for retirement Social Security benefits.

c) Disabled individuals who are entitled to Railroad Retirement or SS benefits due to disability. There is an additional 5-month waiting period for Medicare after disability has been determined.


d) Spouse of a deceased, disabled, or retired worker provided the individual is entitled.

e) Individuals of any age who receive dialysis or a renal transplant for End-Stage Renal Disease (ESRD): Entitlement begins the first day of the month after an individual begins renal dialysis. For those in self-dialysis training, entitlement begins with the first month of training. Entitlement begins the month the individual is admitted to the hospital for a renal transplant, provided that the transplant is performed within 2 months. If this does not occur, entitlement begins the second month before the month of the transplant

Part A benefits are automatically available to persons who fulfill the above requirements. There is no premium.

Part B benefits are voluntary and is available to persons who fulfill the above requirements only if they intimate the Social Security Administration of their intention to take it or not. Monthly premium of $45.50 is payable in this case. For this purpose the enrollment period is fixed.

For Individual of age 65 years and above

A person is considered eligible on the first day of the month in which he attains the age of 65 and is also eligible for social security or railroad retirement benefits. For e.g. Franklin Roosevelt’s 65th birthday is on March 14th 1999. He is eligible for benefits on March 1st 1999. His spouse is also eligible for benefits. Entitlement continues until his death or until the enrollee notifies Medicare in writing of his wish to terminate coverage. For Part B, benefits would be terminated on non-payment of premiums. Voluntary termination of coverage ends on the last day of the month following the month in which the notice to terminate was received. There is a grace period not exceeding 90 days for termination due to non-payment of premiums.

For Disabled individuals

Persons who are entitled to social security benefits or railroad retirement benefits due to disability are also entitled to Medicare benefits. Entitlement under social security disability also extends to disabled widows and widowers between the ages of 50 and 65, certain women age 50 or older entitled to mother’s benefits, and persons age 18 and over who receive social security benefits because they became disabled prior to reaching age 22. Persons who are 65 and above would not receive benefits under this category even if they are disabled. Coverage under this category begins 24 months after becoming entitled to social security or railroad retirement benefits. Entitlement begins the first day of 25th month of disability entitlement and terminates at the end of the month following the month in which disability entitlement ends or at the end of the month prior to the month in which the individual attains the age of 65.

End Stage Renal Disease (ESRD)

Individuals who have end stage renal disease are entitled to Medicare coverage if they are (1) entitled to monthly social security or railroad retirement benefits, or (2) currently insured for old age and survivors insurance benefits, or (3) spouses or Medical Billing Training Page 20 of 207

dependents of entitled individuals and have end stage renal disease. Dependents of eligible individuals are also covered if they also have ESRD.

Part A benefits include

Inpatient hospital care Inpatient care in a skilled nursing facility Care in a psychiatric hospital (upto 90 days in a lifetime) Hospice care and respite care when a terminally ill patient can be

admitted to a hospice. A hospice is a public or private organization that provides respite care, support and symptom management to terminally ill patients and their families.

Nursing home care (patient spends at least 3 days as inpatient in a benefit period)

Home health services such as intermittent nursing care and physical, occupational or speech therapy; part-time services of home health aides, medical supplies and

equipment (no drugs). These patients are generally confined to their homes by

injury or illness.

Part B benefits include

Physician services including surgery, consultations, home, office and institutional services and supplies incidental to physician services; drugs and biologicals that cannot be self-administered; physician therapy; speech pathology; blood and blood transfusions.

Outpatient hospital services, including outpatient diagnostic services and physical and occupational therapy or speech pathology services furnished by certain approved institutions and public agencies; outpatient physician and occupational therapy services (upto a monetary limit per calendar year) furnished by an independently practicing therapist in the patient’s home or the therapist’s office; hospital services furnished to outpatients in connection with a doctor’s services; outpatient (ambulatory surgery) and emergency hospital outpatient services.

Diagnostic x-ray and laboratory tests and other diagnostic tests, including in certain cases, diagnostic x-rays taken in a patient’s home.

X-ray, radium and radioactive isotope therapy. Durable medical equipment such as oxygen, hospital beds and walkers

for use in the home whether furnished on a rental basis or purchased. Artificial devices (other than dental) such as pacemakers that replace all

or part of an internal body organ, colostomy or ileostomy bags and related supplies are also covered; one pair of glasses or contact lenses after cataract surgery is covered if an intraocular lens has been inserted.

Braces and artificial legs. Rural and community health clinic services performed by licensed nurses

and physician assistants plus similar services provided to homebound patients in certain areas.

Certified registered nurse anesthetist (CRNA), nurse midwife and physician assistant services.


Psychologist and social worker services provided in connection with a physician’s service.

Limited chiropatic services, pediatric and optometric services. Ambulance service (when the patient’s condition rules out other means of

transportation). Home dialysis supplies and equipment, self-care home dialysis support

services, and institutional dialysis services and supplies.

Medicare Deductibles

Deductible is a pre-determined amount that the beneficiary should pay before the medical benefits come into force.

The Part A annual deductible is $776 per benefit period. A benefit period is the period beginning with the day the patient is giving inpatient hospital treatment and ends with the day when he is out of the hospital or skilled nursing facility for 60 consecutive days.

The Part B annual deductible is $100.

Medicare Co-insurance

Co-insurance is part of the Medicare allowed amount that the patient is responsible to pay.

Co-insurance for Part A is as follows: ( Check the latest figures as they change yearly)

Inpatient Hospital: 61st to 90th day $194 per day91st to 150th day $388 per day

Skilled Nursing Facility: 21st to 100th day $97 per day101st day & Over Patient pays the entire amount

Co-insurance for Part B is as follows:

20% of Medicare’s approved amount, or 50% of Medicare’s approved amount for outpatient psychiatric services. After the patient has met the annual deductible, Medicare pays 80% of the approved amount (except for psychiatric services).

For outpatient psychiatric services, the co-insurance is 50% of Medicare’s approved amount. This is because Medicare reimbursement is reduced for outpatient psychiatric services.

For example:


Approved Medicare charge $100.00Outpatient psychiatric limitation 62.5%Amended approved charge $62.50Medicare pays 80% 80%Medicare reimbursement $50.00

The beneficiary is responsible for the coinsurance amount of $50 because it is the difference between the Medicare approved amount ($100) and what Medicare paid the provider ($50).

Medigap Coverage

This is a policy provided by private carriers to supplement Medicare’s coverage to cover services not covered by Medicare, deductibles and co-insurance. If a patient has such a supplementary coverage, it is necessary to get the details of such coverage and store it in the patient’s file.

The Medicare ID Card

This is a red, white and blue card. It gives the patient name exactly as it appears in the Social Security records. The Health Insurance Claim Number (HICN) (This is generally the beneficiary’s nine-digit Social Security Number followed by an alphabetic character say 123-45-6789A), Patient’s sex, Effective date of coverage and type of benefits is given in the card.

Participation & Non-participation

Participation means that the physician agrees to accept assignment for all Medicare claims (Assignment is an agreement between the practice and the patient wherein the patient transfers his right to receive benefits to the physician and the physician requests direct payment from Medicare); agrees to accept Medicare’s allowed charge as payment-in-full for his services; agrees to complete and file claims forms for the patient at no charge to the patient and agrees not to bill the patient for services determined by Medicare to be not reasonable and necessary (unless he provided advance written notice and the patient agreed to pay). However the physician may bill the patient for other non-covered services.


Non-participation means physicians do not sign the Medicare contract. The physician has a choice on a claim-by-claim basis to accept assignment. Payment for assigned claims to these physicians is five percent less than for participating physicians.

The limiting charge is the maximum a nonparticipating physician can charge a Medicare beneficiary. This amount is currently 115% of the nonparticipating physician fee schedule. The patient is responsible for the entire limiting charge unless the physician takes assignment on the claim.

A Nonparticipating physician who provides a non-emergency surgical procedure and does not accept assignment must inform patients in writing if charges exceed $500. This is called a surgical financial disclosure. An emergency surgical procedure is one that is performed for conditions that afford no alternatives for the physician or the beneficiary and if delayed could result in fatal consequences to the patient. The surgical financial disclosure shows the estimated amount the patient is responsible for.

The following table illustrates the above statements:

Participating Physician Non-Participating Physician Non-Participating Physician Not accepting assignment

Accepting assignmentPhysician’s charge $110 Physician’s charge $110 Physician’s charge

$110Medicare fee schedule $100 Medicare fee schedule* $95 Medicare fee schedule* $95Medicare payment 80% $80 Medicare payment 80% $76 Medicare payment 80% $76Check goes to doctor Check goes to patient Check goes to doctor

Limiting charge** $109.25 Limiting charge**$109.25

Secondary/Patient Secondary/Patient Secondary/Patient Responsibility 20% $20 Responsibility 20% $19 Responsibility 20% $19Max physician can collect$100 Max physician can collect $109.25*** Max physician can collect $95***Write off $10 Write off $0.75 Write off $15


*Medicare fee schedule for non-participating physicians is 95% of participating physicians’ fee schedule.**Limiting charge is 115% of the nonparticipating physicians fee schedule***A non-participating physician cannot charge more than the limiting charge amount

Medicare Fee Schedule – The Resource Based Relative Value Scale (RBRVS)

The Omnibus Budget Reconciliation Act of 1989 (OBRA, later amended in 1990) changed the way physicians were paid by Medicare. Under the Act, the payment for each service is the product of three factors: (1) A nationally uniform relative value; (2) A geographical adjustment factor; and (3) A National uniform conversion factor.

The relative value for each service is the sum of relative value units (RVUs) that reflect the resources involved in furnishing the three components of a physician’s service: (1) Work; (2) Practice Expenses; and (3) Cost of Malpractice insurance.

The geographical adjustment factor (GAF) for a geographical area is equal to the weighted average of the individual geographic practice cost indices (GPCIs) for each of the three components of the service.

The conversion factor (CF) is a national dollar value that converts RVUs into payment amounts.

Work RVUs were developed primarily by a research team headed by William Hsiao, Ph.D. at the Harvard School of Public Health in a co-operative agreement with HCFA.

Practice and malpractice expense RVUs equal the product of the base allowed charges and the practice expense and malpractice percentages for the service. Base allowed charges are defined as the national average allowed charges for the service furnished during 1991, as estimated using the most recent data available. HCFA used 1989 charge data “aged” to reflect the 1991 payment rules, since those were those were the most recent data available.

Section 121 of the Social Security Act Amendments of 1994 required HCFA to replace the existing charge-based practice expense relative value units for all Medicare Physician Fee Schedule services with new resource-based ones. The Balanced Budget Act of 1997 requires a four-year transition from the existing charge-based system to the new resource-based system beginning on

January 1, 1999. In 1999, the practice expense relative value units are based on 75 percent of the charge-based system and 25 percent of the resource-based system. In 2000, they are based on 50 percent of the charge-based system and 50 percent of the resource-based system. In 2001, they are based on 25 percent of the charge-based system and 75 percent of the resource-based system. In 2002, the practice expense relative value units are based entirely on the resource-based system. In 1999, the implementation of the practice expense transition was implemented in the fee schedule calculation formula. In 2000,


to eliminate confusion, the calculation formula will use the transitioned practice expense value. The payment formula for 2000 is as follows:

2000 Non-Facility Pricing Amount =

[(Work RVU * Work GPCI) + (Transitioned RB Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

2000 Facility Pricing Amount =

[(Work RVU * Work GPCI) + (Transitioned RB Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

The Medicare limiting charge is set by law at 115 percent of the payment amount for the service furnished by the nonparticipating physician. However, the law sets the payment amount for nonparticipating physicians at 95 percent of the payment amount for participating physicians (i.e. the full fee schedule amount). Calculating 95 percent of 115 percent of an amount is equivalent to multiplying the amount by a factor of 1.0925 (or 109.25 percent). Therefore, to calculate the Medicare limiting charge for a physician service for a locality, multiply the full fee schedule amount by a factor of 1.0925. The result is the Medicare limiting charge for that service for that locality to which the full fee schedule amount applies

Let us take a few examples:

Geographical Area = Miami, Florida

The geographical practice cost index for work, practice and malpractice is 1.015, 1.077 & 2.350 respectively.

The conversion factor for 2000 is $36.6137

The formula for calculating fee schedule is:

[(Work RVU * Work GPCI) + (Transitioned RB Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

Procedure 47135 – Liver allotransplantion; orthotopic, partial or whole, from cadaver or living donor, any age

The fee schedule is $5712.52


The work, adjusted practice and malpractice RVU is 81.52, 49.51 & 8.49 respectively[(81.52*1.015)+(49.51*1.077)+(8.49*2.350)]*36.6137=$5712.52

Procedure 33935 – Heart-Lung transplant with recipient cardiectomy-pneumonectomy


The work, adjusted practice and malpractice RVU is 60.96, 42.08 & 13.54 respectively[(60.96*1.015)+(42.08*1.077)+(13.54*2.350)*36.6137=$5089.91

Procedure 70300 – Radiologic Examination, teeth; single view


The work, adjusted practice and malpractice RVU is 0.10, 0.32 & 0.03 respectively[(0.10*1.015)+(0.32*1.077)+(0.03*2.350)*36.6137=$18.92

Medicare as a Secondary Payer (MSP)

Medicare can be secondary to another insurance plan in the following cases:

a) Patient is above 65 and is still working and is covered by an Employer Group Health Plan (EGHP) or spouse who is above 65 is employed with coverage by an EGHP

b) Disability beneficiaries

c) Automobile no-fault insurance or other liability

d) Patient is covered under workers’ compensation

For individuals of age 65 and above, if either they are working or their spouses are working, Medicare can act as secondary insurance provided the benefits of the coverage with their employer is still valid and the employer has 20 or more employees. If either of these conditions is not satisfied, Medicare remains the primary payer. The employer health plan cannot supplement Medicare coverage. The following table will help us in determining whether Medicare is primary or secondary.

Employment/ Primary Coverage statusAge status Spouse 65 years or older


Individual Still Employed

65 years and above Group Health Plan Medicare Secondary62-64 years Not Medicare Eligible Family Health Plan Medicare SecondaryBelow 62 years Not Medicare Eligible Family Health Plan If he has no Part A but purchases Part B, Medicare is

primary. If he has Part A but purchases Part B, Medicare is

secondary.Individual Retired from Employment

65 years and above Medicare primary Medicare primaryBelow 65 Not Medicare Eligible Individual Health Plan Medicare primary

For disabled beneficiaries who are covered by a large group health plan (an employer with 100 or more employees) as a current employee or as a family member of a current employee, Medicare acts as secondary. When an employee or a member of the employee’s family becomes disabled, the large group health plan is primary.

For automobile accident, fall or other liability, Medicare will make payment on conditional basis. If the liability is settled by the no-fault carrier, then Medicare needs to be reimbursed for the payment made.

Similarly for work-related injuries, Medicare will make payment on conditional basis. The primary responsibility vests with workers compensation and Federal Black Lung carriers. Once they make payment, Medicare’s payment should be refunded.

Medicare is also secondary to an EGHP for self-employed individuals who are former employees if the employer provides coverage for such individuals.

A flow chart explaining the process when you can submit claims to Medicare as secondary is attached.

The working aged and spouse provision does not apply:

If the patient is entitled, or could be entitled upon application to Medicare under the end-stage renal disease provision.

To individuals enrolled in Part B only. To individuals enrolled in Part A on the basis of a monthly premium. To anyone who is under age 65. To individuals covered by a health plan other than an EGHP. E.g. one that

is purchased by the individual privately and not as a member of a group. To employees of employers of fewer than 20 employees. To members of multi-employer plans whom the plan identified as

employees of employers with fewer than 20 employees.


To retired beneficiaries (other than spouses of employed individuals) who are covered by EGHPs as a result of past employment and who do not have EGHP coverage as the result of current employment.

The coordination period (the period when Medicare changes from secondary to primary) ceases on:

The last day of the month in which the beneficiary or the beneficiary’s spouse retires.

The day the beneficiary or the beneficiary’s spouse is terminated from the EGHP.

The beneficiary’s date of death.

Medicare will calculate the secondary benefits as follows:

The lesser of the balance amount after primary payment and 80% of Medicare allowed amount if Medicare was primary.

Let us illustrate this with an example:

Example 1

Physician’s charge $100Primary insurance payment $80Balance to be paid by secondary/Patient $20Medicare allowed amount $48Medicare payment 80% $38.40

Since Medicare payment of $38.40 is more than the balance to be paid of $20, MCR would pay the entire $20.

Example 2

Physician’s charge $100Primary insurance payment $50Balance to be paid by secondary/Patient $50Medicare allowed amount $48Medicare payment 80% $38.40

Since Medicare payment of $38.40 is less than the balance to be paid of $50, MCR would pay only $38.40.

Medicare Appeals Process

Appeal

After a claim is processed, Medicare sends the EOBs to the providers determining payment or denial. If the provider feels that the denial or payment is incorrect, a


request can be made for review of a claim. A review is another look at the claim. The request for review must be made in

writing within 6 months from the date of the EOB. Some Medicare carriers have the facility of telephonic appeal that can be explored. In the case of written request for review, the following documents should be sent to the carrier: Copy of EOB, the claim and medical records. A covering letter explaining the need for review would be helpful. The review is made by a completely different team who has not taken part in the original processing of the claim. It is purely based on the documentation sent for review. The determination is made within 45 days from the receipt of the request for review and the decision whether favorable or unfavorable is notified to the provider. If the provider is still not satisfied with the decision, he goes in for a fair hearing.

Fair Hearing

The next step in the appeals process is a Fair Hearing. Fair Hearing can be requested if the disputed amount is at least $100 and not later than 6 months of the review determination. The amount represents the amount that should have been paid according to the provider and not the difference amount. Also the amount may not be of a single claim. It can be more than one claim too. A covering letter with the additional documents as sent for appeal is required for this too. The hearing officer should acknowledge the provider’s request within 2 weeks of receipt. There are three modes of hearing:

In-person hearing

Wherein the provider or his representative appears before the hearing officer in person on the designated date and time notified by the hearing officer and answers questions raised by the hearing officer and produces documentary evidence required by the hearing officer. The hearing officer is a neutral person appointed by the carrier and is aware of all Medicare rules and regulations.

Telephone hearing

Wherein questions raised by the hearing officer is answered over phone. This is less time consuming.

On-the-record decisions

Wherein the decision is based on past information and new information presented by the practice in writing. The Hearing officer will inform decision to the provider’s office in writing within 30 days of the request for hearing. If the provider is still not satisfied with the decision, he goes to the Federal Administrative Law Judge.

Federal Administrative Law Judge.

These Judges are lawyers who work for the Social Security Administration. Here the disputed amount should be atleast $500. The providers should send a letter within 60 days of the hearing decision to the carrier or the local Social Security office requesting Medical Billing Training Page 30 of 207

ALJ’s hearing. The process will the same as that of the hearing officer. The decision should be made and notified to the provider within 15 days of the receipt of request. If the decision is still unfavorable to the provider, the provider can send his request within 60 days to the appeals council.

Appeals Council

This is the last resort. This is done by the Federal District Court and the disputed amount should be at least $1000. Here both the provider and his attorney are requested to appear before the court. The decision made will be final and binding on both the parties.

Site of Service Differential:

Payment for some services that are routinely furnished in physicians' offices are reduced when such services are furnished in the following hospital settings:

Outpatient Hospital

Emergency Room-Hospital

Comprehensive Outpatient Rehabilitation Facility

ESRD Treatment Facility

Inpatient Hospital

Inpatient Psychiatric Facility

Comprehensive Inpatient Rehabilitation Facility

Medicare reduces reimbursement because the physician saves on overhead expenses when he/she performs such services in the above settings. He/she will incur such overhead expenses when he/she performs the services in his/her office.


Insurance Carriers - Medicaid

Medicaid – An operations study

Medicaid is a federal and state plan, operated by the states, which is an entitlement program under the Social Security Administration of the federal government for patients whose income and resources are insufficient to pay for healthcare.

Eligibility

The Medicaid program, jointly funded by the State and Federal governments, provides medical benefits to individuals with low income and resources. It is run by the individual States under broad Federal guidelines. Each state

1) Establishes its own eligibility standards2) Determines the type, amount, duration, and scope of services3) Sets the rate of payment for services4) Administers its own program

Consequently, the Medicaid program differs widely from state to state. It even differs from region to region within a State, since local bodies are also involved in the funding and implementation of the program. Coverage, billing and reimbursement rules also change over time.

Though each state has discretionary powers to set its own eligibility standards, States are required to provide Medicaid coverage to most individuals receiving federally assisted income maintenance benefits, and for related groups not receiving such cash assistance.

Aid to Families with Dependent Children (AFDC)

Recipients of AFDC and Supplemental Security Income (SSI) are all eligible for Medicaid. They receive federal cash assistance. Besides, other disadvantaged groups, who satisfy the AFDC and SSI program criteria, but who do not receive cash assistance are also eligible. Poor children and low-income pregnant women, both of whom are some of the largest beneficiaries of Medicaid, are examples. Some states also include non-disabled adults without children in the Medicaid eligible groups.

Medically Needy Eligibility Groups


Some groups may not satisfy the low-income standard. That is, their income may make them ineligible for Medicaid. But they can still become eligible by "spending down". This means that a person may have an income above the poverty level indicated by the state's Medicaid program. But high medical expenses may offset this margin. When the medical expenses are reduced from the person’s income that person may fall below the poverty level. This is called spending down and thus the person become eligible.

Another way a person becomes part of the medically needy group and qualifies for Medicaid is by paying the state an amount equal to the difference between family income and the income eligibility standard.

Suppose a person's income is $100.00 above the income eligibility level. The person does not qualify. But by paying $100.00 to the state, after deducting any medical expenses he/she has incurred, he/she becomes eligible. The amount, which keeps him/her above the poverty level, is surrendered to the state. Only Medically needy individuals resort to this method. Their incomes will not be low enough to qualify for Medicaid, and not high enough to help them meet their medical needs.

Different states apply different income and resources methodologies to decide on the poverty level i.e. the methods they adopt to measure income/resources level and thus decide on Medicaid eligibility differ widely.

Medicaid Benefits for Medicare Beneficiaries

For certain poor Medicare beneficiaries, called "Qualified Medicare Beneficiaries" (QMB) with incomes below the Federal poverty level and with resources below twice the standard allowed under the SSI program, Medicaid will pay the Part A and Part B Medicare premiums and co-insurance.

"Specified Low-Income Medicare Beneficiaries" (SLBM), those that have marginally higher incomes than the QMBs, Medicaid will pay the Medicare Part B premium only.

The New TANF Program

The Temporary Assistance to Needy Families (TANF) program was introduced recently. This program will replace the AFDC program. Members who qualify for this program also are eligible for Medicaid.

Thus, Medicaid eligible candidates fall under several groups of low-income citizens. It is not necessary that their incomes should be below the Federal poverty level. It depends on whether he/she belongs to a medically needy group, and spends a substantial part of his/her income for medical expenses.

Also, poverty is not the sole eligibility criteria. Just because a person is poor does not qualify him/her for Medicaid. There are lots of poor people without Medicaid coverage. The individual should fall into any of the special disadvantaged groups indicated above.

Restricted Benefits


Sometimes there are restricted benefits that patients impose upon themselves. An example of such benefits is restricted status. Restricted status requires the recipient to see a specific physician or have his or her prescriptions renewed at a specific pharmacy. When a Medicaid patient comes for treatment, the office staff should examine the card for restricted status. If there is any, then only if the physician or pharmacy comes under the umbrella of the practice, can the patient be treated. If the designated physician was not able to treat the patient, then he should refer the patient to this practice. Emergency treatments are exempted from this category.

Claims Submission & Payment

Federal Law requires Medicaid to accept HCFA 1500 for claims processing in states where optical scanning facility is not available. Some states like New York and Georgia have special forms developed exclusively for claims processing by their state and which has optical scanning facilities. Though the Health Care Financing Administration (HCFA) of the Department of Human Services of the US Government is responsible for administering Medicaid, each State Government has its own requirements and they append to what HCFA determines. Hence claims submission in some states may go directly to Department of Human Services, while in some states it goes to county department of welfare and so on.

Medicaid carriers in almost all states have the facility of receiving claims electronically.

Filing Limit – This is the period within which claims need to be submitted failing which claims would be denied for lapse of time. Some Medicaid carriers have this as 1 year from date of service while some have this as 90 days from date of service and so on.

Other insurance plan – It is to be ensured that the patient has no other coverage other than Medicaid. If he has one and it is still valid, then we need to submit it to that coverage first.

Crossover – Crossover is a process wherein claims are automatically being sent to the supplemental carriers by Medicare after Medicare processes the primary claims and makes payment to the providers. The supplemental carriers processes and make payment to the providers. Some Medicaid carriers would have this facility. Here the provider need not have to submit a fresh claim to the secondary carrier.


Insurance Carriers – Blue Cross Blue Shield

Introduction

The origin of Blue Cross Blue Shield dates back to 1929 when a University employee persuaded a group of school teachers to pay $6 every year into a fund. In return the University hospital will give them and their families 21 days of free care every year. This concept worked and spread like wildfire. It has now become a multi-million dollar network covering everything in healthcare. Blue Cross covers hospital services while Blue Shield covers outpatient and physician services. Blue Cross and Blue Shield are non-profit organizations and all money received as premiums are paid out as benefits except for financial reserves.

BCBS ID Card

BCBS ID card is different for different plans. Each Plan has its own design and format for ID card, certificate # etc. Since the number of plans is huge, it is absolutely essential that each card is unique. By looking at the card, we would be able to identify which plan the patient has. Generally

the ID format for a BCBS Plan is 3 alphabets followed by 9 digits except for the Federal Plan where it is R followed by 8 digits.

Plans of BCBS

Reciprocity Plan

A double-ended arrow with the certificate # in between is the identification for this plan. The certificate # is N followed by 6 digits. The coverage enables the BCBS plan


in the state where the services were rendered to pay for the covered services making it unnecessary to file a claim with the subscriber’s out-of-state plan. Reciprocity is a cooperative arrangement between various BCBS companies. Only certain services are covered through reciprocity.

These are:

Surgery. Anesthesia. Technical surgical assistance. Inpatient medical services (medical care visit, intensive care, concurrent

care, consultation). Emergency accident care. Emergency medical care. Radiation therapy and chemotherapy. Elective abortion (as allowed by state law)

The following services are not covered:

Maternity care and surgical services related to complications of pregnancy.

Second surgical opinion. Newborn care, well baby care and immunization. Routine physical exams. Outpatient radiology, ultrasound and nuclear medicine and outpatient

ECG, EEG and other electronic diagnostic services except as part of emergency treatment.

Dental, vision and hearing services. Dialysis. Physical, occupational, speech and respiratory therapy. Mental health treatment provided in a psychiatric hospital or another

special purpose facility. Long term care or rehabilitative psychiatric care, day or night care for

psychiatric conditions and outpatient mental health treatment. Skilled nursing caretaker services.

Central Certification

This is a program that covers the employees of a company that has offices, plants and people in several states and whose employees travel a great deal or change location frequently. The identification number on the subscriber’s card indicates this type of reciprocity. Claims are filed and paid by the local plan where the treatment was rendered. Central certification can be identified on a

subscriber’s card by the map of the United States, which appears in the upper right corner of the certificate.

Federal Employees Program

This is a government plan for providing medical insurance for federal employees. The phrase “Government-wide service benefit plan” appears on all subscriber cards. The subscriber identification number begins with letter R followed by eight digits. The kind


of coverage is important to be noted. FEP 101 (Single); and FEP 102 (Family) are known as high option policies, and FEP 104 (Single) and FEP 105 (Family) are known as low option policies. The co-payment for the high option is lower than that of the low option.

Co-ordination of Benefits (COB)

This is a provision pioneered by BCBS to prevent overpayment of services. With COB, the primary insurance plan is responsible for paying the full benefit amount allowed by its contract. The secondary insurance plan is responsible for any part of the benefit not covered by the primary insurance provided the benefit is covered by the secondary plan. BCBS also refined the COB for dependent children. Here the birthday rule applies. The plan of the parent whose birthday appears first in the calendar year would be the primary plan while the plan of the other parent would be the secondary plan and would be subject to COB. For e.g. Julia and Robert are parents of Christopher. Julia’s birthday falls on Oct 24th while Robert’s birthday falls on Nov 28th. Julia’s plan would be primary and Robert’s plan would be secondary and subject to COB. In case the birthday is identical for both the parents, the plan, which is in force for a longer period of time, would be primary for the dependent. This rule not only applies to BCBS but for other insurance carriers as well.

Methods of Payment

Many BCBS carriers determine physician payments using the lowest of the usual, customary and reasonable (UCR) amounts charged by the physicians. The usual is the fee the provider normally submits for service. The customary is the range of fees charged by physicians in similar specialties for the same service in the same geographic area. Reasonable refers to the fee the insurance company determines after analyzing the customary and usual data received on BCBS claims. Some BCBS carriers are changing over to RBRVS.

Claims Submission

Majority of BCBS carriers accept only HCFA. Some accept UB92 and other forms. Also majority of BCBS carriers have facility of receiving claims electronically.


Insurance Carriers – Managed Care and Other Plans

Introduction and Definition

Managed care is the application of administrative methods to controlling healthcare costs and patients’ access to providers. Managed care’s administrative methods integrate the financing and delivery of medical care for enrollees. They combine an insurance payer with medical resource monitoring and a provider delivery system.

In other words, Managed Care refers to health care insurance plans that are managed in such a way that the COST and QUALITY of health care services and supplies are controlled. The stated objective is to bring the best of health care services to patients at low cost. Managed health care plans operate within a fixed or controlled budget. Such plans also seek to reduce the burden on the health care consumer. Care is "MANAGED".

Managed Healthcare is thus a health care delivery system that aims to control the cost and quality of services rendered by providers and suppliers of health care. Managed care plans to achieve this aim by (a) fixing the rates for each service; (b) monitoring the need for each service, or insist on medical necessity of services rendered; (c) emphasizing preventive care, to help detect and treat diseases before they become serious and necessitate costly treatment.


To control costs, services are monitored to ensure that they are medically necessary. Prior authorization is made compulsory for expensive services. Monitoring of services is either done by a "gatekeeper" physician or through other officials appointed by the plan. A “gatekeeper” physician is a primary care physician (PCP) who is responsible for coordinating and authorizing the services of specialists. In this manner, the gatekeeper PCP is the case manager. A member must always go to the gatekeeper to have the gate opened to other participating providers. This is known as a referral.

Objectives of Managed Care

Organizations that offer managed care plans will say that they aim at offering high-quality medical care at affordable rates. Managed Care plans are generally understood to have the following objectives:

1. Quality Improvement: Health care is monitored for quality and necessity. Consequently, services rendered are more effective and efficient. Physicians are encouraged to render appropriate and timely care.

2. Prevention: Managed care plans encourage preventive care by covering procedures such as annual physical check-ups, cancer screening, prenatal examinations, etc., etc., so that doctors can help either prevent illnesses or detect diseases in their early stages. Diseases can be easier and cheaper to treat when detected early.

3. Care Coordination: Due to the wide range of medical services available, and the growth of medical technology, a patient may need help in deciding what sort of care he/she needs. The patient must be advised of the best methods of treatment or the best facilities available to attend to his/her health needs. Managed care plans provide the concerned medical professionals to ensure that each patient receives the best health care available under the plan.

4. Accountability: Managed care plans make the physicians more accountable for the services they render. Physicians are prevented from wasting money on costly, inappropriate or unexplained services. They are encouraged to adhere to certain treatment standards and conserve health care resources.

5. Affordability: By reducing the burden of out-of-pocket expenses on the member, managed care plans aim to make high quality care affordable. They offer insurance at reduced costs, despite the ever-growing cost of health care.

Types of Managed Care Plans

Managed Care Plans are operated by private companies, which act as the payer. Examples are Prudential Health Care (an HMO) and Independent Health (a PPO).


Physicians sign a contract with a managed care plan to accept the plan’s fee schedule, which is usually lower than the prevailing market rate. The physicians are considered part of a MCO (managed care organization’s panel of providers).

The following are the major managed care plans.

Health Maintenance Organization (HMO):

This is regulated by the State HMO laws. The laws require an HMO to cover benefits for preventive care, which includes routine physician examinations, and other services. Co-ordination of care by a PCP (primary care physician) is required for patients to receive benefits. HMOs also do not provide any benefits for patients unless medical services are provided by contracted physicians. There are two types of payments by HMOs, Capitation and Fee-For-Service. HMOs were the first plan to place the physician’s payment at risk by either Capitation or Withhold. Capitation means HMO’s prepay the doctor for the care of a population assigned to the practice. Withhold means that a certain proportion of the payment due to a physician will be withheld by the HMO (e.g. 10-40%) for a defined period, until the HMO has had time to pay all the claims for that period. If an HMO exceeds its budget for the payment of claims for a period, the withheld money is not paid to the doctor.

Preferred Provider Organization (PPO):

This may or may not be regulated by state insurance laws. It can be regulated by State Insurance laws if they are owned by a private insurance plan or the PPO operates within a state, which has

an insurance law that regular PPOs. PPOs do not cover preventive benefits unless they are regulated by a state, which requires this. PPOs do not generally require co-ordination of care by a PCP. If a patient seeks services outside the panel of contracted physicians, benefits are reduced and the patient must pay out-of-pocket expenses that usually range from 20-30 % of the total costs. If the PPOs are not owned by a private insurance then they are not the payers. They only act as repricing centers for the payers. They decide the fee-for-service that needs to be paid to the providers and forward them to the insurer for payment.

Third Party Administrators (TPA):

This is an organization which contracts with self-insured employers and other insurance mechanisms to provide administrative methods such as provider contracting, utilization controls, enrollment services and claims processing.

Methods of Payment:

Fee for Service: This is fixed charge for the service performed. Either the doctor or the patient submitted a claim and received payment.

Capitation: This is a fixed pre-paid amount based on the number of patients assigned to a practice for a specified period of time.


Other Government & Private Plans

Other Government Plans

In addition to Medicare and Medicaid, we have other government plans such as CHAMPUS, Railroad Medicare & Workers Compensation. Let us discuss in brief about these plans

CHAMPUS (Civilian Health and Medical Program of the Uniformed Services)

This is a cost-sharing program for military families, retirees and their families, some former spouses, and survivors of deceased military personnel. The program is administered by the Office for Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS). CHAMPUS covers all seven uniformed services (Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service and National Oceanic and Atmospheric Administration).

Eligibility:

Active-duty family members (spouses and children to age 21 if unmarried, to age 23 if full-time students, and beyond age 21 if disabled and unmarried).

Retired service personnel and their dependents. If the former military member dies, the eligibility of the spouse does not change unless the spouse remarries. The eligibility of the children remains unchanged if a spouse remarries.

Dependents (the spouse, children, and/or stepchildren) of service personnel who die while on active duty.

DEERS: (Defense Enrollment Eligibility Reporting System). This is a worldwide database of military families. In US, active-duty and retired military personnel are automatically enrolled in DEERS but their family members must be registered by their sponsor. Sponsors are military personnel.

TRICARE: This is a program implemented by CHAMPUS nationwide. It includes managed care and offers CHAMPUS service families three types of coverage-Tricare-Standard, which includes the traditional CHAMPUS benefits; Tricare-Extra, which consists of a PPO network panel with discounted cost sharing and Tricare-Prime, which is a managed care program with annual enrollment requirements and the lowest out-of-pocket costs.


Claims:

The claims filing limit is 1 year from date of service. HCFA-1500 is used for submitting claims. Physician or his representative should sign the HCFA in box 31. For computer generated claims, a signature authorization form should be sent to the carrier.

Appeals:

There are three stages of Appeals.

Reconsideration is the first level of appeal conducted by the claims processor. For this purpose, we need to do the following: a) write to the address on the EOB within 90 days of the date on the EOB. Include a copy of the EOB and other information or papers to support the claim. (b) The CHAMPUS contractor will send a written acknowledgement of the receipt of the claim within 10 days of receiving it. (c) The contractor will review the case and send a reconsideration decision about the claim. If the amount is $50 or less, the reconsideration decision is final. If there is further disagreement and the amount is over $50, ask for a review at OCHAMPUS headquarters. This request must be postmarked or received by OCHAMPUS headquarters within 60 days of the date of the written reconsideration.

Formal Review is the second level of appeal conducted at the CHAMPUS headquarters. To request a formal review, write to CHAMPUS Appeals, Aurora CO 80045-6900. Include a copy of the reconsideration notice and any additional clinical information about the treatment that is appropriate. It is acceptable to write CHAMPUS for a formal review to meet the filing deadline and send the support documentation later. CHAMPUS headquarters will review the case and issue a formal review decision. If the amount in dispute is less than $300, the formal review decision is final. If there is still disagreement and if the amount is $300 or more, the next step is an independent hearing at CHAMPUS headquarters.

Hearing is conducted by an independent hearing officer at a location convenient to both the requesting party and the government. A request for this hearing must be postmarked or received within 60 days of the date on the formal review decision. This is the last step in the review process, and both parties must abide by the decision of the independent hearing officer.

CHAMPVA (Civilian Health and Medical Program for the Veteran Administration)

It is a medical benefit plan for the families of veterans with a 100 percent service-connected disability and the surviving spouses or children of veterans who die from a service-connected disability. These beneficiaries have similar benefits under the same conditions and cost-sharing plans as dependents of retired and deceased uniformed services personnel under CHAMPUS. The same claims processors handle both CHAMPUS and CHAMPVA claims and have the same requirements.


RAILROAD MEDICARE

It is a Medicare plan for railroad retirees administered by the Railroad Retirement Board. It follows the same rules as that of Medicare.

WORKERS COMPENSATION

It is a requirement of the federal government for employers of patients who are injured or become sick on the job. It is operated by various plans chosen by the employer or can be operated by state governments. There is a Bureau of Workers Compensation (BWC) who administers the workers compensation system. Employers may pay premiums into a state insurance fund or to an insurance or managed care plan to administer their workers compensation funds. Some large employers have been granted the privilege by BWC of having their own workers compensation program.

There are five types of compensation for on-the-job injuries and illnesses.

1. Medical treatment and rehabilitation

2. Loss of wages (disability payments)

3. Permanent disability (payments in one sum or weekly or monthly payments)

4. Vocational rehabilitation

5. Compensation to the dependents of employees who are fatally injured (death benefits)

For claims submission, the most widely used form is HCFA 1500 though certain carrier require their own forms to report injury claims. However all of them require the employer information and the injury date on the claims. Without this information no workers compensation claim would get paid. The amount paid by the workers compensation carrier to the provider is in full and final settlement of the claims. If there is any dispute, we can appeal in the form sent by the carrier within the time limit mentioned therein. On no account should the patient be billed for the balance after a workers compensation claim has been paid.

Other Private Plans

In addition to Blue Cross Blue Shield & Managed Care carriers, we have other major private or commercial plans.


In the beginning only Traditional indemnity benefits were provided. These benefits were paid only when a patient is ill or injured. Preventive care was ignored. In view of heavy competition, this has made way for variety of other benefits including preventive care. Unlike government plans where policies and rules are well defined and published, private plans do not reveal their operational policies.

A self-insured plan is one in which the payer is an employer or other group such as a labor union. Examples Bell Atlantic and Teamsters Local Union. The employer or other group assumes full risk for the payment of healthcare services by taking the premium it would have paid to an insurance mechanism and establishing a fund to provide benefits for its employees or group members. A self-insured plan usually contracts with an administrator who acts on behalf of the self-insured plan to process the claims.

Pre-existing condition: A pre-existing condition (PEC) is one which has been diagnosed and treated before the effective date. A plan will not cover pre-existing conditions until the enrollee waits for a period of time, such as 60 or 90 days, during which no treatment is given for this condition. For example, a recently enrolled patient with active cancer who must see a doctor will not be covered for the cancer. Because of PEC, the sickest patients should not enroll in these plans. Often, however, they do not have a choice. The patient is billed for all services that are not covered because of an exclusion in the policy.


PROVIDER ENROLLMENT

Provider/supplier enrollment is a critical function that attempts to ensure that only qualified and eligible individuals and entities are enrolled in the federal carriers like Medicare, Medicaid and other Private Carriers and receive reimbursement for services furnished. Physicians, suppliers, organizations, etc., that wish to be reimbursed for services furnished must enroll in Medicare, Medicaid and other Private Carriers who compulsorily require enrollment in order to submit claims. If not enrolled, payments for the services cannot be issued and the same would be rejected stating the reasons.

The Provider Enrollment Services department is responsible for reviewing each CMS 855 application in its entirety; verifying and validating the information collected; coordinating with State survey/certification agencies and Centers for Medicare & Medicaid Services (CMS) Regional Offices; utilizing various information sources to confirm that the applicant has not had any adverse legal history and maintaining the highest level of confidentiality with all information provided.

In addition, Provider Enrollment Services handles all changes to specialty, address, IRS tax identification numbers, participating status, resignations, and the complete review of provider data file(s).

Applying for a Provider Identification Number (PIN)

A physician/healthcare practitioner must have an individual provider number to submit services to Medicare Part B. A physician means doctor of medicine, doctor of osteopathy, doctor of dental surgery or dental medicine, doctor of chiropractic, a doctor of podiatric medicine, or a doctor of optometry who is licensed to practice by the State in which he or she performs services.

Effective November 1, 2001, there are three new CMS 855 forms available:

855I - Application for Individual Health Care Practitioners855B - Application for Health Care Suppliers that will bill Medicare Carriers


855R – Application for Individual Health Care Practitioners to Reassign Medicare Benefits

The HCFA 855 has been replaced by the CMS 855I and CMS 855B. These forms are used for enrollment as well as all change requests to existing provider information. The HCFA 855C has been eliminated. HGSAdministrators may ask providers to complete the 855I or 855B when change requests are received on letterhead.

The 855R has been renamed to Application for Individual Health Care Practitioners to Reassign Medicare Benefits, and modified slightly.

Initial Enrollment – Carriers are required to process 90% of applications within 60 calendar days of receipt. Ninety-nine percent of applications should be processed within 120 days of receipt.

Unique Physician Identification Number (UPIN)

Unique Physician Identification Number (UPIN). This number is assigned through a registry in California. The UPIN Registry establishes and maintains the files of physicians, health care practitioners and group practices receiving Part B Medicare payments. All physicians/practitioners will receive a UPIN. It identifies each physician/practitioner/group for all billing practice settings. The UPIN number is different from the provider identification number (PIN) assigned by Medicare.

The CMS 855R is used to add a provider to a group account. This form allows Medicare to pay the group for the services that the individual provider has provided under reassignment of benefits. Each provider who wants to join a group must have an active provider identification number with HGSAdministrators and then must fill out an 855R form.

Unique Provider Identification Number (UPIN)a. Services Requiring a UPIN

All Medicare claims reporting referred or ordered services must include the name and unique provider identification number (UPIN) of the provider who referred or ordered the services to be rendered.

All Medicare claims reporting the following services must always report the name and UPIN of the referring or ordering provider. If


this information is not reported, the claim will be rejected. Claims that are rejected must be resubmitted for payment with the appropriate UPIN information reported.

Based on the address information available in the Form 855 , payments would be sent to that address only by the Insurance companies. That address would be treated as Pay-to Address and the same should be printed in Box – 33 of the CMS Form. But Medicare and Medicaid, they would not go by the information available in Box – 33 and they will refer the address mentioned in the Enrollment Form and all payments and information would be sent that address only. If there is any change in the address mentioned, then the same information should be notified in Form 855-C. Based on modified information, insurance carriers would update the changed information in their system.

Employer Identification Number (EIN):

This is basically a Tax Identification Number which would be allotted to a group and or the hospital or any collection of doctors.

This is a tax identification (tax id) number of the group into which the doctor has joined. This number is allotted by the IRS for the purpose of submitting the tax returns. The group needs to show this number in all claim forms and correspondence with the carrier.

W-9 Form:

This is a “Request for tax payer identification number and certification” form. This shows the provider’s individual tax id # (SSN) or the group tax id # (EIN) along with the pay-to address. This can be used for updating the tax id # and the pay-to address with the carriers. This should be signed by the provider.

EDI Enrollment

EDI is Electronic Data Interchange. Certain carriers have the facility to accept claims electronically. For this purpose we need to enroll the providers with the EDI Department of the insurance carriers. This is mandatory requirement in the case of Federal Carriers such as Medicare and Medicaid. This is a separate process apart from the above Provider Enrollment process. We need to fill in a separate EDI enrollment form for providers and send them to the carrier. The carrier will then add the provider in the EDI database. Only then can we submit claims to that carrier for that provider electronically.


Patient Enrollment and Insurance Adjudication

The Patient – Enrollment process

Every patient should have an insurance policy if he/ she does not want to get burdened by the entire cost of medical services. He/ she can do this during the open enrollment period. This is a period wherein an individual can select an insurance plan by filling up an enrollment form. The insurance plan can be either a government plan or a private plan or a managed care plan. Once enrolled, revocation is not possible until the start of the next enrollment period. The plan selected becomes the insurer who agrees to accept the risk of underwriting medical benefits for a premium. In some cases, no premium need be paid by the enrollee. It may either be funded by the employer (workers compensation plans) or by the government (Medicaid plans).

Once the enrollment is through, it becomes a policy. A policy is a contract between the patient and the insurance plan; it is a certificate of coverage. The enrollee is also called the insured or policyholder or subscriber or member. A dependent of the enrollee may also be covered under the policy, if the policyholder has family coverage. A dependent may be a spouse, child or any other person defined in the policy.


A policy does not become effective on the date of enrollment. There is a waiting period, depending on the insurance plan, from the date of enrollment to the date the policy becomes effective. Benefits become eligible only from the effective date.

The enrollees receive an identification card (ID card) giving details of the policy, the plan, name of policyholder, dependents, if any, id number, plan number and group number. The card also lists out the co-pays for certain plans. On the reverse side of the card, a brief description about the plan, benefit exclusions such as work related injuries, pre-existing condition etc., mailing address for claims etc., would be described.

The Insurance - Adjudication Process

Once the plans receive claims from the providers, they process the claims. This is called adjudication. Adjudication is the operational process carried out by a plan from receipt of the claim through completion of the explanation of benefits (EOB). If the claim is not properly completed, it will be denied. Only clean claims will be adjudicated. A clean claim is only that is properly completed in accordance with the insurance company’s rules and regulations.

Even if all the insurance rules are followed in reporting a claim, the claim may still be denied if is received after the filing limit. Filing limit is the deadline for claims submission. Every insurance carrier has its own filing limit. Some may be 90 days while some may be 1 year. This limit is calculated from the date of service to the date of receipt of claim by the insurance company.

During the process of adjudication, any cost sharing arrangements are noted in the EOB. A cost sharing arrangement is an arrangement between the insured and the insurer relating to sharing of payments for medical services and is outlined in the policy. The main purpose behind this arrangement is to avoid abuse of benefits by the patients. Also called as out-of-pocket expenses, these are generally co-payments, deductibles and co-insurance.

Co-payments are dollar amounts that the enrollee pays the provider directly towards cost sharing of certain services such as office-visits, mental health visits and hospitalizations. These are given in the ID card such as $10 for an office visit, $20 for mental health visit etc. Deductibles are fixed dollar amounts that an enrollee must pay for covered services at the beginning of each calendar year, before medical benefits begin. Co-insurance is another form of cost sharing paid by the enrollee direct to the provider and is based on a percentage of allowed services.

The first plan to which claims are being submitted is the primary insurance. When patients have more than one policy either as a policyholder or as a beneficiary, the plan which pays first is the primary insurance. The secondary insurance is the plan which pays after the primary had paid. A copy of the primary insurance EOB is sent to the secondary insurance along with the claim. Secondary insurance pay for co-payments, deductibles or other cost-sharing arrangements of the primary insurance.


In order to avoid overpayment by the secondary insurance, insurance plans tend to co-ordinate benefits with one another. Coordination of benefits involves the coordination of operations between two or more plans to assure that no plan issues payment for benefits in excess of 100 percent of provider’s services.

The following cases show which plan should be primary when there are more than one plan from which the patient is entitled to receive benefits:

The patient’s own plan unless the patient is retired and covered by the policy of an active employee. For e.g. Elizabeth has her own policy in MEDICARE as well as she is also covered under her husband’s policy BUREAU OF WC. She is retired while her husband is working. Here the husband’s policy BWC will be her primary insurance.

The plan which is in effect for a longer period of time when the patient has more than one policy. For e.g. Barbara has two plans: CIGNA is in force for 10 years while OPTIMUM CHOICE is in force for 7 years. Here CIGNA is the primary insurance.

The plan without a COB clause in its policy. For e.g. CARE PLUS HEALTH PLAN has no COB clause in its policy. It processes and makes payment irrespective of whether any other insurance has processed the claims and paid or not. AARP has a COB clause in its policy. It makes payment only after payment by the other insurance. Hence CARE PLUS HEALTH PLAN is the primary insurance.

The plan of the custodial parent where the parents are divorced and both policies cover the children. For e.g. Pete and Jane are children of William and Hanna who have been divorced for 2 years. Pete is in the custody of Hanna while Jane is in the custody of William. Hanna has OXFORD covering both the children, while William has UNITED

HEALTH CARE covering both the children. For Pete the primary insurance will be

OXFORD while for Jane it would be UNITED HEALTH CARE.

The plan of the parent whose birthday falls first during the calendar year (other than in situations where they are separated) and both policies cover the children. For e.g. Let us take the above example assuming William and Hanna are living together along with the children. William’s birthday is on 5 th

March while Hanna’s is on 27th September. For both the children the primary is UNITED HEALTH CARE.

It is not out of place to explain subrogation here. Subrogation is a process wherein the insurance feels the liability to pay for the services vests with another insurance


company and marks it so. For example, a patient has fallen from the stairs in his neighbor’s home is a case of potential subrogation.

Here the patient’s insurer would investigate the possibility of having the neighbor’s home insurance company pay for the services. For this purpose, the patient’s insurer would specify a reason code in the EOB informing the provider that the claim has been suspended for subrogation and needs to be submitted to another insurance company.


Medical Billing Process – Flow Chart and Introduction

As discussed the three parties in medical billing are patients, providers and the insurance carriers. The process starts with the patients arriving at the hospital and ends with the providers getting payments for their services. This is a very complicated process considering the complexity of the procedures, rules and regulations involved


SCANNING TO INDIA

PRINTING IN INDIA

CODING

PATIENT DEMOGRAPHICS ENTRY

CHARGE ENTRY

REPORTS TO DOCTOR’S OFFICE

DENIALS UPDATION

PATIENT BILLSELECTRONIC CLAIMSPAPER CLAIMS

CASH TALLYNG

INCORRECT ADDRESSCASH POSTINGCLAIM DENIALSCASH POSTING

ANALYSISANALYSIS

DETAILS UPDATIONCASH TALLYING

MONTHEND REPORTS

PATIENT FOLLOWUPINSURANCE AR FOLLOW UP

PROCESS - MEDICAL BILLING

COLLECTION AGENCY

DOCTOR’S OFFICE IN US

Patient with Insurance Patients with no Insurance

Payments Denials

Patient respondsPatient does not respond

QUALITY AUDIT

and the number of people involved in the process. This can be made simple if proper systems are in place both at the hospital and the medical billing unit.

Patient Demographics Entry

Basic Collection of Information and Documentation

This is a process wherein patient information is collected from the patient at the time of entry at the hospital. The hospital front office staff has to do the following functions in this regard:

When a patient first requests an appointment, before the formal registration process begins, the practice requests the patient for the name of his or her insurance company. For e.g. if a patient has an insurance plan that requires him or her to seek services only from a contracted physician and the practice does not include a contracted physician from that plan, but still the patient insists on an appointment, the hospital informs the patient of his or her obligation to pay the physician in full on the day of the appointment. If a patient belongs to a plan, which requires a referral (an authorization from a patient’s PCP), the correct referral information - the proper paper form or an authorization number is collected.

After fixing up the appointment of when the patient comes into the hospital, the staff gives a registration packet to the patient. This contains the hospital brochure, the financial policy and the registration form. With the hospital brochure, the hospital welcomes the patient, describes in brief about the hospital history and structure, about its doctors, staff, facilities etc. It also gives the scheduled appointment timings of various doctors. The financial policy details about payments by patients for treatments not covered by insurance, non-contracted payers etc. The registration form contains the patient information and the insurance information. The patient or an authorized person should sign the registration form at two places - one for authorizing the physician to release medical information in order to submit a claim and one for assigning benefits to the physician. Normally this packet would be mailed to the patient immediately after his appointment is fixed so that when the patient arrives on the appointment day, he or she would have completed filling in the registration form.

The hospital must also request the patient to give a copy of his insurance cards. This is very much necessary since the card copy contains the insurance plan details and the correct identification # of

the plan and the claims mailing address. A copy in the patient’s file is also necessary for the fact that at the time the patient leaves the hospital, the card copy can be verified to see if any co-pay needs to be collected from the patient.

A copy of the patient’s driver’s license is also necessary. This is required because, patient can be traced of his whereabouts when he has moved or left no forwarding address.

Pre-authorization:


This is a requirement to be adhered to before the patient gets registered for treatment. Also known as pre-certification, this requires notification to the plan of certain planned services and all elective inpatient hospitalizations before they are rendered. Depending on the plan, either the patient or the provider must seek pre-authorization for these services. Certain managed care plans require the patients to go through a contracted physician participating in their network. If the patient gets treated through a physician not part of the network then the managed care plan require the physician to call the plan and notify them of the treatment before hand. Only after their approval can the treatment be proceeded. If the treatment is done without the approval, then the managed care plan will not reimburse the physician for their services nor can the physician bill the patient. This approval is called pre-authorization and a copy of this should be made available in the patient’s file before the treatment is rendered. Another requirement is to obtain a second opinion from an impartial physician regarding medical necessity of the procedure to be performed. A service is deemed medically necessary when-

It is appropriate for the diagnosis being reported.

It is provided in the appropriate location.

It is not provided for the patient’s or his/ her family’s convenience.

It is not custodial care. (Custodial care is care that can be provided by people who are not trained medical professionals.)

Once the authorization has been granted, an authorization # would be given. This number should be reported on the claim for the service.

Patient Demographic Entry:

Patient Demographic Entry is described here with Proactiv software in mind. However the principles are the same in whichever software you use for demographics entry. During demographics entry the following fields are required.

PATIENT DETAILS

Patient Account #, Patient Last Name, Patient First Name, Patient Middle Initial,

[Patient Account # is a ten digit number selected using the following format. The first three digits are for the Company #. The next digit (fourth) is for the last digit in the year. The next three digits (fifth to seventh) are for the Julian date of the date of service. The last three digits are for the serial number of the patient in the batch. Julian date is the serial number of the date in the calendar year. For e.g. Julian date for Jan 31st would be 031 while for Feb 1st would be 032.

The American Reporting format of a person’s name is last Name first followed by a, (comma), First name second and the Middle Initial third. For e.g. if a patient’s name is JOHN F SMITH then we should report it as SMITH, JOHN F. The comma after the last name is very important.]


Patient Sex, Patient Date of Birth,

[American system of reporting date is Month/ Date/ Year (MM/DD/YYYY). For e.g. if the date of birth were March 25, 1975 then it would be reported as 03/25/1975. If no date of birth is given in a patient record, it is a general practice to take it as 01/01/1901. But we should use this according to the requirements of the specialty. We cannot do this in Pediatrics where all patients are children.]

Patient SSN,

[SSN refers to Social Security Number. This number is allotted to all American Citizens by the Social Security Administration of the United States of America. This is a nine-digit number as 12-345-6789.Even if this number is not available you can give 99-999-9999 since this number is not relevant for submission of claims. But in a majority of cases this number is same as the insurance id number.]

Patient Address (PO Box/ Street address, City, State and Zip code), Patient Phone #, Bill Insurance Only (Yes/ No),

[In certain cases, we are not supposed to bill the patient after insurance makes payment even if there is a patient responsibility in the Explanation of Benefits. In this case we should answer this field in the affirmative.]

If patient is self-pay, the self-pay box needs to be checked.

[Self-Pay means that the patient does not have insurance coverage and he agrees to accept the billed charge as his responsibility. If the patient record gives such an indication in the insurance coverage details, you need to check this field. Similarly if no insurance information is given in the demographics, the patient record is taken as self-pay.]

GUARANTOR DETAILS

Guarantor Account #, Guarantor Last Name, Guarantor First Name, Guarantor Middle Initial, Guarantor Sex, Guarantor Date of Birth, Guarantor SSN, Guarantor Address (PO Box/ Street address, City, State and Zip code), Guarantor Phone #

[In certain cases a person other than the patient will be responsible for all expenses. This person is called the Guarantor. We need to capture the Guarantor’s information during demographic entry. The Guarantor Fields are very much necessary if the patient is a minor.]

EMPLOYER DETAILS

Employer # Medical Billing Training Page 55 of 207

[The patient’s employer information is given in the demographics. This information should also be captured in demographic entry since this is vital in many cases, particularly for Workers Compensation patients. The Employer details are stored in the employer master. You need to give the code in the demographics screen. If there is no employer record stored in the master for a particular employer, you should add them in the employer master. If there is no employer mentioned in the demographics, you need to take it as Unknown.]

COVERAGE DETAILS

There are three modules-Primary, Secondary and Tertiary. Each module with contain the following:

Insurance ID, Insurance Name, Patient Type, Effective from, Effective to, First ID, Second ID, Relation, Detailed Relation

Subscriber Details

Subscriber Account #, Subscriber Last Name, Subscriber First Name, Subscriber Middle Initial, Subscriber Sex, Subscriber Date of Birth, Subscriber SSN, Subscriber Address (PO Box/ Street address, City, State and Zip code), Subscriber Phone #

[A Patient may have more than one insurance coverage. In such a case, one of them may act as the Primary Coverage and process the claim and make payment before the others do. If the Primary Coverage makes payment in full, there is no responsibility for the Secondary and Tertiary coverage. If the Primary Coverage sets apart a portion of its allowed amount as co-insurance, then the secondary or the tertiary or the patient will be responsible for it.Every plan will provide its member with their id card showing the Plan name, member name, policy number, group/ plan #, effective dates. At the back of the card it shows the claims mailing address and phone #. Based on this card copy and the information in the patient registration form, the above particulars have to be filled in.]

Once you have completed all of the above information you can update the demographics. You can keep the demographics pending if any of the vital information is not available.

You may encounter the following during patient demographics entry:*A Patient Record already existsIf you come across a patient in the batch for which you are doing demographics which already exists, then you need not register that patient again in the system. However you need to verify if the information given in the demographics sheet is same as that in the system. If information other than the coverage differs you can change it directly in the system and note that change. If the coverage differs, you need to archive coverage. Archiving coverage is the process by which you remove the existing coverage and add a new coverage to the patient demographics in the system. The existing coverage is stored in the coverage history for that patient. However if the new coverage is workers compensation, you need to register that patient again because workers compensation is for a particular incident for injury at work place or when on Medical Billing Training Page 56 of 207

duty and overrides the other health coverage the patient may have for that date of service.

Charge Entry

Basic Collection of Information and Documentation

When the initial procedure of registration of patients is completed, the treatment is carried out. During this activity, the physician has to fill in the charge sheet or the super-bill showing details of the treatment rendered. This form shows the patient name, date of service, time of service, doctor performing the service, procedure description and diagnosis description. This form should be signed by the attending doctor. A sample charge sheet/ super-bill is attached. Based on the procedure & diagnosis descriptions, the CPT/ HCPCS codes and the ICD-9 codes would be filled in. This is an internal form and would be used in filling up the claim to be sent to the carrier. This should not be used as a medical record to be attached along with the claim.

Sometimes there may be situations where there is more than one diagnosis to be fixed for a particular procedure. In such cases it should be made clear on the charge sheet or super-bill.


Coding of procedures and diagnosis

This is a process whereby the procedures and diagnosis given in the charge sheet are coded. As discussed earlier the most common coding systems used for procedures and diagnosis are CPT-4 and ICD-9 respectively. Based on the doctor’s medical impressions and the indications in the super-bill we need to fix a proper code for the procedure and diagnosis. This is a complicated, lengthy and time-consuming process and involves lot of thinking and analysis. Since incorrect coding leads to breach of compliance, we need to be very careful in this aspect.

Some carriers, particularly Medicare, require only certain diagnosis to be reported for certain procedures since according to them other diagnosis is not medically necessary to be treated with this procedure. Hence HCFA has set up a CPT-ICD9 linkage wherein they state the list of ICD9 codes which correspond to a CPT code. In other words, it specifies what may be the kinds of diseases/ ailments for which this treatment is being given.

Here it is very important to describe the following terms:

Unbundling: This refers to a situation where two procedures are reported where one is included in the other or there is a third procedure which covers both for a lesser value (lesser than the value of both the procedures put together).

Upcoding: This refers to a situation where a more complex procedure is used than is warranted by the diagnosis reported. A simpler procedure could be used instead.

Pre-coding

Before the actual data entry is commenced for demographics and charge-entry, it is desirable to pre-code all those fields wherein a code is available. For e.g. in demographics, patient account #, employer # & insurance company # are ideal for coding. Similarly in charge-entry, doctor #, referring doctor #, facility id, place of service and modifier are ideal for coding. If this coding is done before hand, it will be simple & fast for the data entry person and will save him/her a lot of time in searching for the code or adding masters.

Charge Entry

The basic document for charge entry is either the charge sheet or the super-bill or the medical record giving basic information of codes required for charge entry.


Charge Entry is described here with Proactiv software in mind. However the principles are the same in whichever software you use for charge entry. During charge entry the following fields are required.

BATCH DETAILS

Accounting date,

[This is date fixed according to a schedule by the billing office based on which the entries are made. This may be a daily schedule and should be opened and closed every day.]

Batch #,

[This is a number again fixed according to the requirement of the project. This is four-digit number and is generally the Julian date followed by the serial number. For e.g. If we are processing patients for dates of service 03/25/2000, then the batch # would be 0851, 0852 and so on. Julian date is the serial number of the date in that year i.e. Jan 31st would be 031, Feb 1st would be 032, March 1st would be 061 and so on.]

Patient Account #,

[This is the number, which you have allotted to the patient during registration. If you type this number the other particulars such as the patient name, insurance coverage and the patient type would default.]

Facility ID,

[Facility is a synonym for hospital. We need to capture the name of the hospital where the services were rendered. The names of the hospital would be stored in the facility master. You need to give the id # from that master for the hospital for which you are doing charge entry.]

Doctor ID,

[The Doctor who performed the service i.e. the attending doctor should be stated here. The doctor’s particulars are stored in the doctor master. We need to mention the id # of the relevant doctor here.]

Ref Dr ID,


[Referring Doctor is a doctor who has referred the patient to the doctor who performed the service. These doctors’ particulars are stored in the referring doctor master. You need to mention the id # of the referring doctor here.]

PCP ID (optional),

[PCP is Primary Care Physician. A PCP is one who has diagnosed the patient first before the attending doctor treats him. In some specialties/ states, PCP is a vital link in obtaining information for insurance processing. We need to get the PCP name and phone # in such cases.]

Place of Service,

[Give the correct place of service code for inpatient, outpatient, office consultation, emergency room, ambulatory surgical center etc.]

Admit Date, Discharge Date, Injury Date,

[Though these are not compulsory fields it is desirable to provide this information. Injury date is a must for Workmen’s compensation claims.]

Referral #, Prior authorization #

[As explained above, for cases which require prior authorization the authorization or the referral # should be stated. If there is an authorization or referral on file but no number has been allotted, we should just state “referral on file” in the above field.]

LINE ITEM DETAILS

From Date of Service, To Date of Service, [Date of service is the date on which the treatment is rendered to the patient. This may be just one date or a range of dates. We need to fill in this information as given in the charge sheet/ super-bill.]

Procedure,

[Here you will have to give the key-in code for the CPT/ ASA/ HCPCS code for the procedure performed. The complete procedure details are stored in the procedure master. We need to specify the key-in code here.]

Modifier, [Enter the appropriate modifier code. All modifiers are stored in the modifier master. Most common modifiers used are 26 for Professional Component, TC for Technical Component, 50 for Bilateral, 59 for Distinct Procedural Service etc.]

Diagnosis,


[Enter the ICD-9 code here. You cannot enter more than 4 different ICD-9 codes in a ticket since HCFA has the capacity to accept only 4.]

Units, [This is stored in the procedure master in most cases and will default once you enter the procedure. Otherwise you will have to enter the number of units here. In Anesthesia Billing, the number of units will be time units + base units.]

Amount.[This is also stored in the procedure master. If will default once you enter the procedure.]

Once you complete all items in charge entry you need to update the charge. You will have to take a charge summary and check your work.

Locum Tenens & Reciprocal Billing

Locum Tenens is an arrangement whereby the regular physician hires another physician to take care of his services while he is on leave for reasons such as illness, pregnancy, vacation or continuing medical education. The regular physician may submit claims and receive payment for services provided by the substitute physician during his absence. The substitute physician also called locum tenens physicians are paid on a per diem basis or fee for service basis and are considered independent contractors rather than employees of the physician’s practice.

The following basic criteria should be met in order to bill under a locum tenens arrangement:

The regular physician is unavailable to provide the visit services.

Patient has arranged or seeks to receive the visit services from the regular physician.

The substitute physician does not provide services over a continuous period of more than 60 days. Any service beyond the 60-day period would have to be billed under the substitute physician provider # and payment would be sent to the substitute physician.

The regular physician uses Q6 modifier in Box 24D of HCFA-1500 when reporting the services.

The regular physician pays the substitute physician on a per diem or fee for service basis for the services rendered.

The regular physician must keep on record all such services and must be able to produce it on demand.


The continuous period of 60 days begins with the first day on which the substitute physician provides covered visit services.

Also a physician who has left the group and for whom the group has engaged a locum tenens physician as a temporary replacement may still be considered a member of the group until a permanent replacement is obtained.

Reciprocal billing arrangements are those in which a substitute physician is not paid for the services. Instead, he has an agreement with the regular physician for whom he is covering to provide patient care coverage in exchange for equivalent coverage for his practice by the regular physician when he needs the coverage himself.

The rules are similar to that of the locum tenens arrangement except that payment on a per diem or fee for service basis is not existing here and the physician uses Q5 modifier in Box 24D of HCFA-1500 when reporting the services.

Claims Audit


Audit Department’s primary function is to see that there should not be any error in the Claims sent to Insurance Companies and they have to ensure that all the quality checks are correctly performed in the Company.

Basically Audit person should be experienced in data entry process of Patient Demographic and Charges and should have thorough knowledge on Billing Rules and Regulations of Charges. After receiving files from Charges department, details should be updated in the Excel Spread Sheet.

While checking Patient Demographic, audit person carefully check Name,Address, SSN, DOB, H Ph, W Ph, Policy ID, Coverage details, Subscriber Details, Employer details, etc.

While checking Charges, audit person carefully check DOS, Procedure Code, Diagnosis Code, Modifier, Units, Value, TOS, POS, Ins Number, Doctor Number, Location, Prior Authorization, Referral, etc..

They should check each and every field of patient demographic entry and charges entry before submitting the claims for transmission.

If any error is found in the data or any data not entered in the system should be informed to the Charges department through mail for correction and the same information should be updated in the Excel Sheet for record purpose.

After corrections are over , audit department has to check again and approve the claims for transmission.

Errors done by the entry persons should be noted down and mail sent totheir department managers stating the errors. If the entry persons do errors regularly then warning messages to be issued to entry person to avoid


unnecessary errors in the entry part.

After auditing Patient Demographics and Charges Files, information like Entered by Whom, Entered date, # of charges, # of patients, correction details, audited by person ( name), audited date should be updated in the Excel spread sheet.

Claims Generation and Transmission

Introduction

The next step after demographics and charge entry is claims generation. Claims may be paper claims or electronic claims.

A claim is a comprehensive pooling of all data relating to a patient for a particular treatment. All registration, charges and provider information is contained in this form which is sent to the insurance carrier for processing. The data presented in this form should be 100% accurate since payment or otherwise to the doctor for the patient’s treatment is based on the information provided in this form. Hence this should be thoroughly audited before sending to the carriers.

Paper claims

There are various types of forms for paper claims. The most widely used form is HCFA-1500 designed by the Health Care Financing Administration. This is a red color form in white background. The other forms used by specific carriers are UB92, Green-and-white form for NY Medicaid, Georgia Medicaid Form 8 etc. These forms are set up in the billing system that you are using in order to enable you to print directly from your system.

Proper filling up of all required fields in the HCFA-1500 is the most essential function of a billing company. Attached are the basic instructions in filling up each field in HCFA-1500 and a copy of the HCFA-1500. (Annexure B)

Once the claims are generated and printed, they should be packed and sent to the carriers. We need to use proper window covers for this purpose.

The red HCFA-1500 forms are designed for OCR (Optical Character Recognition) scanners. When the computer printed HCFA runs through the scanner (around 2400 claims per hour can be processed), it stores in the computer all the data available in the HCFA. This eliminates data entry by the insurance processing staff on receipt of the HCFA. This is the reason why HCFA should be properly aligned (all fields should be


printed in proper places) while printing. The following precautions should be taken while printing:

Use the most common type of font.

Use only black inked impressions

Print only in the white areas. Any prints in the shaded areas will not be OCRd.

Use only UPPER cases.

Do not erase or use correction fluid after printing. If there is an error, print a new HCFA.

Do not highlight.

Fold only at the proper places.

Above all the print quality should be clear and alignment should be perfect.

Electronic Transmission

Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through magnetic tape, diskette or using modem and now through internet too. The claim information is directly loaded into the insurance company’s computer system.

The major advantages of this method are less administrative costs, no concerns of claims being lost in transit, no concerns regarding data entry errors being made by insurance staff while processing claims, less rejections, less turnaround time between the process of data and process of claim by the carrier and above all we can receive reports of the number of claims sent and received by the carriers.

Medicare pays electronic claims within 14 days while paper claims take 27 days in processing. In some cases there is a facility for Electronic Fund Transfer (EFT) wherein the carriers deposits the check directly into the bank account of the provider or the group. Here again the number of days it takes to send the check through post and then manually depositing them into the bank is avoided.

For Federal Carriers, in order to transmit claims electronically, we need to enroll the providers through EDI of that carrier. These carriers have facility of transmission directly and not through any clearing house. Certain other carriers also have the facility of accepting electronic claims, but they have to send through a clearing house.

One of the major clearing houses for commercial carriers is NEIC – National Electronic Information Corporation. For this purpose we need to establish vendors who has the


facility of receiving claims from the billing office, performs edit checks which are more or less equal to the carrier requirements and has numerous carriers registered under it for forwarding claims electronically.

These vendors accepts data in a single format and edits, sorts and distributes the data into formats that are acceptable by various plans. They charge a fee that is generally a fixed amount per claim. We have two vendors for sending claims electronically to non-Federal carriers-Halleys & Fast Claim.

Reports to be maintained

Print Claims to be printed list – This is a list of claims, which needs to be printed (to be printed on paper or to be sent electronically). Every time you fetch claims, this list should be generated through a query. This list should show separately direct electronic claims, electronic claims to be sent through clearing house, primary paper claims, secondary paper claims, secondary

piggy backed claims. A control log should be maintained showing a list of each category of

claims and their value every week/ transmission.

Transmission confirm reports – After every transmission, the transmission department will forward the confirm reports. These reports would be available within 24 hours of transmission. If for any reason it is not received within this time we need to rigorously follow up with the vendor for receipt of these reports. These reports should be carefully scrutinized and any rejections should be attended to immediately (or within 24 hours).

Transmission control log – The transmission confirm reports should be logged into a file for every transmission.

Dispatch log – Claims are dispatched to the carriers once in a week. The weekly dispatch report showing the list of claims is maintained.


Patient Bills Generation

Bills are sent to the patient for two purposes:

When the patient is a self pay i.e. he has no insurance coverage

When the patient is responsible for co-insurance, if any, after the primary and the secondary, if any, makes payment.

In addition we may also bill patients in the following cases.

Insurance denies claims as:

Coverage terminated

Coverage not valid for DOS

Benefits exhausted

Procedure not covered

Applied to deductible

Unable to identify patient


Requested information from patient not received by insurance

Insurance information in demographics insufficient and no phone # available even through directory assistance for calling insurance.

It should be remembered that we should not bill MEDICAID patients unless they are denied for the reason coverage terminated or coverage not valid for DOS.

Patient bills show the amount due from the patient and the due date of payment.

The following are the contents of a patient bill:

Date of printing of bill

Patient’s/ Guarantor’s Name

Patient’s/ Guarantor’s Address

Patient Account #

Patient Balance

Address to which payment should be remitted

Date of service

Description of procedure performed

Name of attending doctor

Billed amount

Amount paid by Medicare/ other insurance

Amount paid by patient

Adjustments

Balance due

Due date of payment

In addition we now have the facility of printing the reason “why the patient was billed” in patient bills in addition to showing the insurance name.

Some billing companies have the facility to receive payments through credit cards in addition to cash and check.

Bills are sent to patients in cycles. A Bill Cycle denotes the number of times a bill is sent to the patient. It also denotes the period between each cycle. This period may Medical Billing Training Page 68 of 207

vary by specialty. Some may be 15 days while some may be 30 days. Bill cycle will change only if there is no activity between two cycles. Bill cycle will be zero before the first bill is sent. Let us take a couple of instances to explain this.

For e.g. Patient JOHN BROWN is a self-pay patient.

Case # 1: He has a bill for DOS 12/01/1999 for $50. The bill was sent on 12/06/1999. The bill cycle will be 1 after sending the bill. The patient paid $25 on 12/23/1999. The second bill was sent on 01/10/2000 for $25. The bill cycle will still be 1 after sending the second bill. This is because, the balance in the second bill is a fresh balance after the patient has paid.

Case # 2: After the first bill was sent on 12/6/1999, the patient comes back for treatment on 12/10/1999. The bill for both the dates of service will be sent on 12/13/1999. This is in addition to the bill sent on 12/6/1999. The bill cycle will still be 1 here. The patient pays for the first bill for $25 on 12/23/1999. After the next bill sent on 01/10/2000 the bill cycle will still be 1. If no payment or no fresh treatment occurred after the bill sent on 01/10/2000, then bill cycle will be 2 after sending the next bill on 02/14/2000.

Cash Transaction

Introduction

Once the claims reach the carriers and they complete processing, they issue a check and prepare an Explanation of Benefits (EOB). The checks and the EOBs would be sent to the pay-to address with the carrier or in the HCFA. Pay-to address is the common address that the provider has set up to receive checks and EOBs from carriers and patients. This is most likely a PO Box address set up in arrangement with the bank where the provider has an account. The checks and EOBs are received on all working days. The bank deposits the checks every day into the provider’s account, prepares a deposit statement and sends the statement, EOBs and copies of checks every day to the provider. The provider forwards them to the billing office for posting.

Explanation of Benefits

Explanation of Benefits or EOB is the detailed statement of the carrier’s determination of the claims processed. The determination can result in a payment or a denial.


The Explanation of Benefits contains the following information:

Name of the payer, Name of the provider, Pay-to address, Name of the patient, Name of the member, his id #, date of service, procedure code, amount billed by the provider, amount allowed by the payer, co-insurance, deductible, amount paid by the payer. The amount paid by the payer is equal to the amount shown by the check.

The following terms in relation to the above needs explanation:

Allowed Amount:

This is the amount allowed by the carrier. Not all carriers and in all circumstances allow the entire amount billed. Certain carriers have fee schedules based on which they make payments. These fee schedules determine the allowed amount. A Fee Schedule is a list of reimbursement amount for each procedure. These vary according to various localities. This allowed amount is the maximum that a carrier will pay for a particular procedure.

Co-Insurance:

This is a part of the allowed amount, which the carrier has determined that the supplementary insurance or the patient is responsible to pay. This will be mentioned clearly in the EOB and should be billed to the secondary carrier or to the patient.

Deductible:

This is an amount that the patient owes the carrier every year apart from the premium.

Write Off:

This is an amount that the provider has to remove from his books. There are two types of write off: One is contractual write off and the other one is adjustments. Contractual write off are those wherein the excess of billed amount over the carrier’s allowed amount is written off. The fee schedules of each carrier will be loaded in the billing system. When you are posting the EOBs these fee schedules in the system also called system allowed amount would pop up. The difference between the billed amount and the system allowed amount will be the write off, if the EOB allowed amount is less than the system allowed amount. Otherwise the difference between the billed amount and the EOB allowed amount would be the write off. Adjustments are amounts such as discounts, professional courtesy and other special items that are identified by the provider as those that need not be collected or collected at a lower rate.

Cash Posting


With the EOBs and the check copies and the deposit statement, we should start posting cash. The following is the process of cash posting:The deposit statement should first be checked with the EOBs and check copies received. Check whether all EOBs and check copies mentioned in the deposit statement are received. Check the deposit total. The date of deposit will be the date in the deposit statement. The batch number will be the Julian date of the date of deposit followed by the serial number. Put each deposit file in a folder and write the following on top of the folder: Name of the Project; CASH DEPOSIT FILE; Date of receipt; Date of Deposit; Batch #, Number of checks and the total amount.

Cash Posting is described here with Proactiv software in mind. However the principles are the same in whichever software you use for cash posting. During cash posting the following fields are required.

BATCH DETAILS

Accounting date,

[This is date fixed according to a schedule by the billing office based on which the entries are made. This may be a daily schedule and should be opened and closed every day.]

Date of Deposit

[Date of Deposit is the date as given in the deposit statement and is the date the bank deposits the checks received in the lock box.]

Batch #,

[This is a number again fixed according to the requirement of the project. This is four-digit number and is generally the Julian date followed by the serial number. For e.g. If the date of deposit is 03/25/2000, then the batch # would be 0851, 0852 and so on. Julian date is the serial number of the date in that year i.e. Jan 31st would be 031, Feb 1st would be 032, March 1st would be 061 and so on.]

Lock box #

[This is PO Box # given for the pay-to address where the checks and EOBs are received]

# of Checks, Total Amount

[Enter the # of checks and total amount from the deposit statement]

CHECK DETAILS

Check #, Check date, Check AmountMedical Billing Training Page 71 of 207

[Enter the check #, check date and check amount for the check copies received]

Payment from: X Insurance . Patient

[Check the correct box]

Filing Ref., EOB/RA #, EOB Date

[For Filing Ref., Enter the line item reference. The line item reference will be as follows: For e.g. 01.02.03252000 where 01 will be the serial number of the check in the batch/ deposit statement; 02 is the batch #; and 03252000 is the date of deposit.EOB/RA # is the number given in the Explanation of Benefits/ Remittance Advice.EOB date is the date given in the EOB.]

Insurance/Patient

If you have checked Insurance in the Payment From Field above, you will have to give the insurance company #. If you have checked Patient in the Payment From Field above, you will have to give the Patient account #.

SELECT A CLAIM

Claim

Give the claim #. Claim # is the ticket number followed by 1, 2 or 3 for primary, secondary and tertiary insurance companies respectively.

Claim

Line Item

Other Accounts

Patient Payment

CLAIM

Select this option if you are going to post the check by claim irrespective of the number of line items in the claim. Once we check this option, the details with reference to the claim are displayed in the claim status box. The following details are displayed: Patient Name, Insurance, Claim Status, Patient Type, First ID, Second ID, Par/Non-Par and the details of amount posted for a particular check.

In addition to the claim status box, the following box appears on the screen


Post By Claim

Claim Bal Paid Amount

Co-Ins

Deductible

Unprocessed

EOB Allo Amt

Write Off

Claim Bal: This will show the total balance in the claim (For e.g. if there are three line items in the claim and the total billed amount

is $150, then $150 will be displayed in the Claim Bal box).

Paid Amount: Here you will have to post the actual paid amount as given in the EOB.

Co-Ins: Here you will have to post the actual amount of Co-Ins or Co-pay as given in the EOB.

Deducible: Here you will have to post the deductible amount as given in the EOB.

Unprocessed: In the following instance we keep the certain amounts in unprocessed:

When the EOB allowed amount is not equal to Paid + Co-ins + Deductible, then we keep the balance amount

in unprocessed.For e.g. Billed Amount: $100; Paid Amount: $25; EOB

Allowed Amount: $50; the balance amount of $25 i.e. the difference between the EOB allowed amount and the

paid amount is kept as unprocessed.

EOB AllowedAmount: EOB Allowed Amount is generated automatically.

(EOB Allowed Amount = Paid Amount + Co-Ins + Deductible).

The System allowed amount will popup once you are in this field.

Write off: Write off is the difference between billed amount and system allowed amount.

We generally post the secondary payments by claim when we have earlier flipped the primary claim.

LINE ITEM

Select this option if you are going to post the check by line item.Select this option if you are going to post the check by line item. Similar to the claims option, once you check this option, the claim status box will appear with the same details as given above.


In addition to the claim status box, the following box appears on the screen

Post By Line Item

L No Line Bal Paid Amount Co-Ins Deductible Unprocessed EOB Allo.Amt Write Off

L No: Here the Line No of the claim is displayed.

Line Bal: This will show the total balance for the line item that is displayed.

Paid Amount: Here you will have to post the actual paid amount as given in the EOB for each line item.

Co-Ins: Here you will have to post the actual amount of Co-Ins for the line item as given in the EOB.

Deductible: Here you will have to post the Deductible amount for the line item as given in the EOB.

Unprocessed: In the following instances we keep certain amounts in Unprocessed.

a) When there is a vast difference between the system allowed amount and the EOB allowed amount or the paid amount is very low.

b) When one or more line items has been denied or not been considered for payment in the EOB.

EOB Allowed Amount: This is generated automatically.

(EOB Allowed Amount = Paid Amount + Co-Ins + Deductible) for each line item. The System allowed Amount will popup once you are in this field.

Write off: Write off is the difference between the Billed Amount and the System Allowed Amount.

OTHER ACCOUNTS

Select this option if you are going to post the check not as a regular payment, but as an excess payment from insurance/ patient, other non-billing receivables etc.

The following payments are posted in the Other Account category based on the following situations

Unposted:


The following category of payments are kept unposted: If a patient for or from whom a payment is received is not traceable in the

system. If the payments are received for an existing patient in the system but for a

DOS not billed by us. If a payment has been received for a claim which requires AR verification. If only the check is received but EOB not received.

For payments kept in unposted for reasons (3&4) once the necessary information has been obtained, the unposted entry has to be retrieved from the system and posted.

Offset:

The following category of payments are offset: If there is an adjustment in an EOB shown by the insurance company of a

claim previously paid incorrectly. If we have posted in excess for a particular claim (For e.g. if we have posted

$48 instead of $45 to be posted, we have to give an offset of $3.)

Advance Payments:

The following category of payments are posted as advance payments: If the patient makes payment of co-pay at the time of service.

Refunds:

The following category of payments are posted as refunds: If the same carrier has paid the claim twice. Payment received from a carrier for a claim already paid by another carrier. Payment received from both the carrier and the patient. If the patient has paid for the same ticket twice.

Interest:

The following category of payments are posted in interest: If in an EOB there is an additional payment made apart from the allowed

amount denoting interest for delay in payment

Capitated Payments

The following category of payments are posted under this heading: If any payment has been received for a capitated patient (which the

insurance has paid the doctor under the agreement.) it has to be posted here.

Incentive

The following category of payments are posted under this heading: Additional payments received from Medicare due to the facility being in a

HPSA (Health Professional Shortage Area). These are areas that are shortage of doctors. These areas may be in rural villages or in a big city. It may be the


whole state of just a small town. The providers get 10% bonus on Medicare payment for services rendered in

these areas. In order to get this bonus, we need to put a “QU” modifier in the claim if

service was rendered in an urban area and “QB” modifier if service was rendered in a

rural area.

PATIENT PAYMENT

Select this option if you are going to post the check received from a patient against a patient account. This is patient posting.

Various Status of a Claim involved with Cash Posting.

a) If the EOB Allowed Amount is less than the System Allowed Amount (which is normally assigned based on the fee schedule). In this case we need to identify whether the system allowed amount is set higher. If not, we need to find out whether this can be appealed.

b) If one line item is not paid when there are two or more line items in a claim. In this case, we need to appeal the claim.

If the EOB Allowed Amount is more than the System Allowed Amount, may be reviewed and if there is a genuine excess payment by the carrier, the excess payment may be refunded. However if the excess is due to the fact that the allowed amount in the system is low, then it should be revised.

PDetails

If a check is not fully posted and to be posted at the near future it can be kept in pending and can be retrieved by checking the box (Pdetails) from where one can select the particular check after selecting the batch in which the check detail pertains.

Unapply Claims that are kept in Other Accounts [Unposted-(Patient not found, Not our DOS, Ins verification required, EOB required), Refunds, Advanced Payment etc.] when needed to be posted can be retrieved by checking the Unapply box from which the particulars can be retrieved by selecting from the various sections of Other Accounts.

Problems faced during posting

1. When the total paid amount as per EOB does not tally with the check amount, the entire amount can be kept in unposted under the reason – Ins Verification Required and can be sought to the insurance for clarifications.


2. When the EOB is not legible or there is no EOB attached with the check, the entire paid amount of the check can be kept in unposted under the reason-EOB Required and can be sought to the carrier or the provider for rescanning the EOB.

3. If the Amount paid is more than the claim balance, then the excess Amount can be posted under refunds which is in Other Accounts.

4. If the carrier pays for a line item which is not in our system, the amount paid for that line item can be kept in unposted under the reason – Ins Verification Required and can be sought to the insurance for clarifications.

5. If the billed amount does not tally i.e. the billed amount as per our system and as per the EOB differs then too the payment is kept unposted and sought for insurance verification.

Flipping Of a Claim:

If the primary/secondary carrier denies the claim stating that the procedure is not covered or for some other reason for which the patient is responsible, the claim balance can be flipped to the secondary carrier/subsequent carrier or the patient.

If the carrier pays the patient directly and the patient pays the provider, then the claim has to be flipped to transfer the balance to the patient and subsequently to be posted as patient posting.

Separate Write Off.

If the claim is low paid and the balance is un-collectable even after efforts are taken to appeal the claim, then a separate write off can be taken by changing the status to NC (not collectable).

Similarly if the carrier pays the patient directly according to its fee schedule and the balance is not collectable, the balance can be separately written off.

Cash payment deletion.

If a payment has been posted incorrectly or to be revised, the previous posting has to be deleted. You can do this by giving the claim # or the ticket # in the delete option. The deleted payment will be stored in Unposted and can be retrieved for further posting.


Claims Denials and Regular Mail Receipts

Introduction

Not all claims, which are processed by the carrier, would be paid. If the claim does not meet the requirements of the carrier or if the carrier requires further information on the claim, the claim would be denied. The denial would be received either in the same EOB as that of the payment or in a separate EOB. Sometimes the claim form itself would get returned requesting correction and resubmission. Sometimes the carrier would send a letter requesting information or documentation.

All the denials are loaded in the system, corrections carried out and claims resubmitted.

Regular Mail Entry

Irrespective of the nature of the regular mail, we need to enter them in the system so that we can track them easily and generate reports.

During regular mail entry the following fields are required

REGULAR MAIL

Reference #

[Here enter the file # of the regular mail/ denials]

Mail Date

[Here enter the date of the denial/ EOB]


Received From

[The source of the regular mail i.e. from whom did you receive the regular mail-Medicare, BCBS, United Health Care, Patient and so on.]

Contact phone #

[The phone # if available as given in the EOB]

Mail Type

[Select from the pull down menu-Newsletters, Manuals, Regular Mail from carrier, Regular mail from patient etc.]

Based on selection of the mail type, the next field will appear.You need to give the Claim # or the Patient account # or the News letter/ Manual # etc.

DENIALS/REJECTIONS

Action on Regular Mails

This is a most important function in the process flow of data. Unless this is taken care of, insurance AR will only be on an upward trend. Regular Mails contain tremendous source of information. We need to use the information not only to take care of the particular claim in question but also globally for all claims for the carrier and for all similar issues elsewhere.

Let us discuss in detail as to what are the types of issues that you would encounter in the regular mail:

Basic denials requiring corrections:

Incorrect id # - This may be due to the following: (a) the source document may have an incorrect id. (b) data entry error (c) the id format may not be in the billing rule. If the denial is due to (a), then we need to document such denials and notify the client immediately. If the denial is due to (b), we need to find out where the breakdown is and why this has escaped the eyes of the charge entry person and audit. If the denial is due to (c) i.e. if the id # entered is not in proper format, then we need to immediately set up a billing rule which will trap this kind of error and we can correct the claim before sending it out in the first place.

Incorrect or No modifier – This may be due to two situations: (a) the ignorance of the charge entry person as to what modifier should be applied for the particular procedure and (b) data entry error. In either case if a proper billing rule is set such that for these procedures this modifier should be used, then any charge without that modifier will not be generated as a claim. This can be identified before hand and corrected.


Coverage not valid for DOS; Coverage Terminated; Benefits Exhausted – These are patient related. However if we had the effective dates of each coverage established, then the first two kinds of errors can be identified at the front end itself before the claims are generated. As regards the last one i.e. Benefits exhausted, this may be due to the fact that the patient’s policy will pay for a particular procedure only once during a year or once during a life time or the insurance company’s general rules for a particular procedure may be only once reimbursable. If it is the latter it can be identified beforehand by setting up a billing rule for that procedure and that insurance company. If it is patient policy specific, then this can be known only when we receive the denial. The ultimate solution for all these cases is to bill the patient.

Non-covered services – The member’s policy does not cover the service provided. Here also we can bill the patient. However we cannot bill a Medicaid patient for this denial in certain states.

Unable to identify patient – This may be due to two things: (a) the coverage details given in source document may be incorrect and (b) data entry error. If this is due to the latter, it may be due to the fact that the operator has entered the patient name or the id # or the insurance company number incorrectly. This is a serious error and we need to find out why the system had failed to track this. We should correct this and resubmit the claim immediately. If it is due to the former, then such errors need to be documented and notified to the client. However follow up needs to be done to correct the claim and resubmit.

Require medical records or Denied for Medical Necessity – In the first opinion of the carrier, they may feel that the procedure may not be necessary for the diagnosis specified. Hence the request for medical records. We should pull out the medical records from the charge file, take copies of it, attach it along with the claim with a covering letter and send it. Analysis should be done to resubmit all claims with the given procedure-diagnosis combination for the insurance carrier with medical records.

Applied to deductible – The patient would not have met his deductible for the year. Hence the carriers would adjust the deductible due from the amounts payable to the provider for the patient account. Since deductible is the patient’s responsibility, we need to bill the patient for the amount applied to deductible.

In addition to denials, we also receive News Letters and Manuals. News Letters are periodical publications of the insurance carriers, which they regularly send to providers. You will receive them in regular mail. They contain information such as the latest decisions by various medical bodies, new policies on medical care, changes in existing reporting requirements by providers and other rules and regulations. Manuals are published once a year with periodical updates by the insurance carriers. These contain the complete medical policies and billing information with respect to that carrier. It mainly contains the claim submission instructions for that carrier with respect to each specialty. We need to carefully store these valuable documents since they are references during the billing process.


Records Keeping

Records Keeping is an important process in Medical Billing and documents to be kept for a minimum period of six years as per Government’s instructions. Documents should be available to submit for inquiry, appeal, review, refunds, etc at any point of time to the Government or Insurance.

Most of the Client Offices would not send original Patient Demographics,Charges, Checks , EOB Copies, Documents, etc. to Chennai Office. They would scan the copies and send it as a file to Chennai. So if we loose ormisplace any document and if we are not able find it, then we may have to ask Client Office to scan the original and send it to us. This will createa bad impression about our company as well as about our process.


Based on the above it is very clear that proper process and formalitiesto be followed for keeping files in the racks or in any storage places.There are several methods followed by departments for keeping files and the details have been given in the following points.

Patient Demographic Files - Normally Demographic files are arranged based on the documents scanned date from Client Office. So when the Patient Number is alloted, scan date would be included in the number allotted for Patient Account. Whenever client requires any patient’s information, system can be referred to and details can be found. Based on the information available, files can be located from the storage place. This is very easy process but scan date reference should be noted down in the excel sheet or in any storage format. (ex – Patient # 50021202001). Following information should be clearly mentioned in the front page of the File:Scan File #, Scan Date #, # of pages, Total Patients, Total entered, Co#, Name, Pending if any, Entered date, Entered by, Reasons, etc.

Charges File - Mostly Charges files are arranged based on Treatment Date/ Service Date. But some times files are arranged in Batch wise, scan date wise, week wise, etc. i.e. based on the information received from the Client Office and based the decision taken by department heads. However they will see that service date is included in the any type of arrangement made. Whenever they require charges file for a particular service date for a particular patient immediately they will note down the service date and refer to related service date file for the required patient. Following information should be clearly mentioned in the front page of the File :Scan File #, Scan Date #, # of pages, Total Charges, Total entered, Co#, Name, Charges on hold, pending if any, Entered date, Entered by, Reasons, etc.

Cash File - Mostly Cash files are arranged based on Deposit Date wise. But


some times files are arranged in Batch wise, scan date wise, etc. i.e. based on the information received from the Client Office and based the decision taken by department heads. However they will see that Deposit date is included in the any type of arrangement made. Whenever they require charges file for a particular deposit date for a particular patient immediately they will note down the deposit date and refer related deposit date file for the required patient. At the time of posting Cash, cash person would enter the deposit date information in the description column of the cash posting screen in the system. (ex – 01.01.011002) Following information should be clearly mentioned in the front page of the File :Scan File #, Scan Date #, # of pages, Total Deposit, Total entered, Co#, Name, Un posted if any, Entered date, Entered by, Reasons, etc.

Regular Mail File - Regular Mail files are arranged based on receipt date From the Client Office. Normally Client Office used to send all mails through Courier to the Chennai Office. So the date when Chennai office Receives the parcel would be mentioned in the Regular Mail file along withCompany Number and Name. The same information would be given in The excel spread sheet and patient accounts in the system. Whenever any Patient account is referred and files are required for verification, immediately based on information given in patient accounts, files can be easily retrieved. (ex – 313FLOR011002). Following information should be clearly mentioned in the front page of the File :Courier #, Courier Date #, # of pages, Total Action taken, Co#, Name, Entered date, Entered by, Reasons, etc.

After taking the files for reference or taking copies, files to be properly placed and kept in the Rack. Rack should be very clean and files details are to be written in the sketch pen and all files should be easily retrievable condition. If the folder is not in good condition or any document not kept properly, then folder to be


changed immediately and documents to be properly placed. As mentioned in the beginning, files to be kept in proper condition for a minimum period of six years and arrangements should be made in the office for keeping all files.

If the racks or storage place is full then files to be put in Boxes and kept in the separate place. At the time of transferring files to Boxes, file details should be clearly written and should be pasted in the visible place of the Box. A separate log should be maintained stating the details of boxes and files which are kept in boxes.


Claims Analysis

Introduction

There may be some claims which would have been sent to the carrier but would not have reached them or would have kept pended with them for want of certain information or would have reached them but not registered in the system due to certain problems. These issues can be identified through follow up calls made to the carriers.

Each Insurance Company would have representatives to handle queries from providers on the claims sent by them. These representatives can be reached during office hours (generally 8am – 4pm EST-Eastern Standard Time) at the phone numbers listed. We have a call center working in the night (EST day) to make calls to insurance carriers and to patients based on work-orders given by the analysts. The duty of the analyst is to analyze and identify accounts that need to be called.

Analysis

Analysis is the most essential part of billing. An analyst is a person who monitors the receivables such that it is well within control. He should also keep in mind that the main objective of a billing company is to maximize collections. He/ She should work towards it and set his work methods such that his goal is attained. For this purpose, the analyst should set a target every month of what his collections would be for that month taking into account various factors such as the average turnaround time and unresolved issues. Thus there are two major functions of an analyst – Maximizing collections and Bringing down receivables. Let us discuss each in detail.

Maximizing collections

Setting of Targets

In order to set the target the following should be identified first:* The normal turnaround time of payment for each carrier (major carriers)* Set an average turnaround time for the project as a wholeThen work out the following:* Take the total insurance AR (Accounts Receivable) for the project as a whole* Eliminate claims filed/ re-filed during the period starting from the date this target is prepared to going back to the completion of the average turnaround time date i.e. the claims which are within the average turnaround time* Eliminate claims that are beyond this period but which has certain issues which have still remained unresolved.


* On the balance arrived at, apply the average collection rate for the project as a whole. This would be the target for the project for that month.The analyst should work towards this target.

Duties of an analyst

The basic duties of an analyst are apart from the above:

Should constantly keep track of electronic claims.

Should constantly keep track of paper claims.

Should keep eyes open for any major rejections – clearing house/ carrier.

Should constantly keep watch on EOBs received from major carriers for payments, pay-to address, provider #s etc.

Should constantly get himself/herself updated on the latest in billing.

Should compulsorily go through each regular mail since they are the source of a lot of information.

Should be thoroughly aware of all the billing rules for the specialty, which he takes care of.

Should advise his co-staff of any changes in data entry rules.

Should ensure that AR days meet industry standards.

Should co-ordinate with the call center crew/ Client coordinator and solve problems.

Should ensure that claims for every carrier goes electronically and work towards achieving it wherever possible.

Bringing down receivables

We can categorize the outstanding claims into 5 broad reasons:

CLAIMS NOT IN SYSTEM

CLAIMS DENIED

CLAIMS IN PROCESS

CLAIMS PAID


CLAIMS PENDED

Let us discuss each category in detail.

CLAIMS NOT IN SYSTEM

There may be various reasons why insurance carriers say claims are not in system.(a) The claims mailing address may be incorrect.(b) The claims have been sent inadvertently to another insurance company.(c) The individual provider #, group provider # or the tax id # being used is

incorrect or does not tally with the one available in the insurance company’s records.

(d) There has been a bombed transmission left unidentified.(e) There has been a transmission rejection not acted upon.(f) The claims have not been sent out at all in the first place either by

transmission or by paper.(g) The claims would be in transit.(h) The insurance company would have a backlog in processing of claims.

CLAIMS DENIED

If the rules and regulations of the insurance company are not followed when reporting a claim, the claim will be denied. The insurance company sends an Explanation of Benefits (EOB) describing in detail why the claim was denied.

The following may be the reasons why denied claims may still be sitting in the books.(a) The denial would have been received and entered in the system but action

not taken.(b) The denial would have been received but not entered in the system and also

no action taken.(c) The denial would not have been received and the information that the claim

was denied was received only through follow up call and no action has been taken.

(d) Action has been taken on the denials received or through follow up call but the corrected claim has not been resubmitted.

(e) Certain denials may require information from the provider or from the hospital such as an authorization #. If no action is taken to obtain this the claims will be just sitting in the books.

CLAIMS PENDED

Sometimes the claims may be PENDED by the insurance company for various reasons:

The following may be the reasons why claims would be PENDED.(a) The insurance company may require some additional information to further

proceed in processing of the claim. This information may be required either from the provider or from the patient and still not been submitted.

CLAIMS IN PROCESS


This information is either received through follow up call or by way of a regular mail (EOB). Until actual payment is posted against the claim, claims in process will still remain in the books. But once you have identified claims in process, it should ultimately either be paid or denied. If this turnaround doesn’t take place within a reasonable amount of time, investigation is required.

CLAIMS PAID

After claims have been paid by the insurance company, the AR analyst heaves a sigh of relief because one more claim has been reduced from his burden. But there are certain cases where even after checks have been issued by the insurance company, the claims are still outstanding:

The following may be the reasons why PAID claims would still remain in the books.(a) The checks issued by the insurance company, but not sent.(b) The checks issued by the insurance company to the correct address not

received by the billing office.(c) The checks issued by the insurance company to an incorrect address not

received by the billing office.(d) Cash received has not yet been posted.(e) Cash received has been kept in unposted.(f) Cash received has been posted to an incorrect claim.(g) Claim would be sitting in the books as Low Paid but in reality it may not be

so.

The analyst should find out whether the claims outstanding fall into any of the above category. If so, he should not only take corrective action but also ensure that the system check exists such that in future such errors do not occur. If every analyst performs his duty to the core, we will never face any problems in AR days and collections.

Let us discuss the AR strategy of major types of carriers.

Medicare

Average AR days:For electronic claims 30 daysFor paper claims 45 days

Filing Limit:For dates of service from 1st Oct. 1999 to 30th Sep. 2000 31st Dec. 2000For dates of service from 1st Oct. 2000 to 30th Sep. 2001 31st Dec. 2001

Appeal Limit:Six months from the EOB date. Medicare makes payment in 14 days for claims transmitted electronically and 27 days for claims transmitted on paper. Giving some time for posting of checks by the carrier, Medical Billing Training Page 88 of 207

depositing in bank account, clearing of checks and receipt of EOBs at the billing office there should be no claims outstanding greater than 30 days for claims transmitted electronically and 45 days for claims sent by paper.

Medicaid


Filing Limit (for certain states):New York Medicaid 90 days from DOSTexas Medicaid 95 days from DOSPennsylvania Medicaid 180 days from DOSFlorida Medicaid 1 year from DOS

Since Medicaid is a state insurance plan, the processing time varies from state to state. Overall, you should not have any outstanding for more than 45 days for electronic and 90 days for paper claims. Since the filing limit for Medicaid claims is only 90 days for certain states (Some states have 180 days while some 1 year), we need to ensure that all claims reach the carrier within the first filing limit. This is very important because claims which do not reach the carrier within the filing limit would be blindly denied for crossing the filing limit and has to go through appeal process wherein you have to prove with supporting documents that you have submitted the claim within the filing limit.

BCBS


Filing Limit (in general): 1 year from DOS

BCBS has various plans covering all states. Each one of them has different rules and regulations. There are local plans and out-of-state plans. You need to be clearly focussed on where you should submit the claims. Also the id formats for each plan differ.

Utilization Review

Here the emphasis on paid claims. In the above section we have been concentrating on how to tackle unpaid claims. Here we would be discussing how to tackle low paid claims.


Low paid claims are those where the amount paid is less than the allowed amount. For this purpose, as far as possible we need to gather the allowed amounts of all procedures by various carriers. Medicare is the only carrier which publishes its fee schedule openly. Other carriers may also publish them but may not be available freely. We need to request for it. Majority of the carriers do not have a fee schedule. They follow the UCR (usual, customary and reasonable). We need to establish the UCR for all major procedures for major carriers and any payments below this amount should be questioned. This is a separate review apart from the regular AR analysis and need to be constantly done. This needs to be carefully done since some or many of the claims may not form part of the AR outstanding as write off would have been taken for the balance amount.

We need to appeal these claims with a covering letter and a copy of the EOB explaining in detail what should have been paid and why and what has been paid. Constant follow up is also necessary in this regard.

Insurance Calling

The call center function in co-ordination with the analyst is the most important function in billing. They are the persons who actually speak with the other parties in billing viz. The insurance and the patient.

In an ideal situation if all required & accurate information is obtained from the patient by the hospital and from the hospital by the billing office in time, this function may not have much importance. But in reality it may not be so. There may be quite a few cases where the information obtained from the patient is inadequate or even incorrect. Sometime there may be cases where the hospital may not maintain proper documentation. All these may amount to claims not being paid. Hence in order to get this information from the patient or hospital and in order to find out from the insurance as why the claims are not paid, this function assumes importance.

We have a call center team who uses a toll-free line to discharge this function. They are provided with a certain script for calling and they raise questions based on this script. This script is loaded in a software called Lotus Notes and the callers record the outcome of the calls here. The analyst’s work-order would be seen in the screen ‘review notes’. The following day, the analyst would review the outcome of the calls made and take appropriate action on the claims. If they need further clarification, it goes back to the caller for calling again.

The analyst and the caller should be aware of call facilities of each insurance company. They should keep a record of a list of phone #s, time of availability, contact persons, fax #s, AVR (Automatic Voice Response) numbers of each insurance company wherever available.


Certain insurance companies have AVR or ARU (Automatic Response Unit) facilities wherein you can get the claim status information through this. Here you should give the following information after dialing the AVR number:The patient/ member’s id #The provider numberThe date of serviceThese should be given in the proper format as per instructions given in the AVR. Once this is done, the AVR gives the following information:*claim has been paid for $… on ……*claim has been denied on …..If you need more information, you will have to talk to the rep through the insurance company claim status phone #.

Certain insurance companies have FAX facilities wherein you can call the carrier for claim status and if you find that the claim is not in their system, you can fax the claim to them immediately. This process will speed up the claims processing and ensure faster inflow of money. The caller should notify the analyst of the request by the rep to fax the claim. The analyst should generate and print the claim and provide it to the caller for faxing. The analyst should have a list of insurance companies, which accept claims by fax and utilize the facility to enable speedy processing of claims.

Patient Calling

In most of the Companies, they do not encourage doing Patient Calling from here. Because the caller should be very polite, very co-operative, not to use any irritating words and should talk friendly manner to the patients. Otherwise patients would go to the Court claiming that the caller has irritated or tried to misbehave or threatened them.

Normally patients are being contacted for getting following information:

To get the payment due from patient

To get the patient’s insurance coverage details

To get the patient’s address, SSN, DOB details


To get the Medical Records and Operative notes from Patient

To get the Insurance Payment from Patient if the insurance Sends payment directly to patient

To get the Employer details if necessary

To get the Subscribers information from the patient

To get the doctor details, referring doctor details, admission date,

Discharge date, if necessary.

If the insurance denies to pay stating that patient has to call and Confirm the treatment to insurance, then patient would be Called and inform them to contact insurance.

Budget Payment and Collection Agency

Moving Patients to Budget Payment

Some times patient may not be able to pay full payment of co-pay dues, co-insurance dues, Deductible dues or any balance mentioned by insurance. They would be ready to pay their dues in installments i.e. monthly fixed payments. Making the patient to come under Budget


Payment System for paying their dues in installments is called as Budget Payment.

AR people have to discuss with their Supervisors and as per their discussion, they need to put the patient into monthly installment payment schemes. They should clearly state that this arrangement to minimize the patient’s burden and patient should not stop any monthly payments to the DoctorsOffice.

We need to keep those patients in a separate Bill Cycle or in separate creditstatus and a Control Log to be maintained all relevant patient details. If the patient does not pay their dues properly, then we need to inform the patient that their accounts would be moved to Collection Agency.

Moving Patients to Collection Agency

If the patient does not make any payment for his dues and not giving proper response for the calls, not attending calls, always stating that patient is not in the station and refusing to pay dues, then Billing office would be sending three bills to the patient and after 90 days, if there is no response, then thepatient account would be moved to Collection Agency.

After identifying the patient accounts which are to be moved to Collection Agency, an excel spread should be prepared and sent to US office for Approval. Once approval is received from US Office, then the patient Account can be moved to internal collection agency or external collectionAgency. This process should be followed at the time of each and every Patient is to be moved to collection agency.


There may be an internal collection agency or an external collection agency.Their main function is to trace the patient and compel the patient to pay theDues or inform the patient that they may have to face legal action.

Internal Collection Agency would be setup by Billing office itself and they would send letters to patient requesting them to pay or there may be a legal action against them. There would not be any percentage or any share for the internal collection agency if they collect money frompatient. But in External Collection Agency, if they get payment from patient, then they would get approximately 35% of the collected money. The percentage is varies from collection agency to collection agency.

Normally Billing Office may not have their own Collection Agency. Because collection agency require more man power, need to spend more time, need to have people in various places and need to spend more moneyfor searching patients, etc. So most of the billing offices hire the ExternalCollection Agency and handover their accounts to them.

After handing over the accounts to Collection Agency, patients account Balance would be changed as Zero and the balance would be moved to Collection Account in the system. Once the payment is received then theBalance would be retrieved in the patient account and payment would beApplied.


Financials and Month End Reports

Daily Reports

After the daily routine of demographics, charge entry, claims processing etc are done, the accounting day is closed. This is a process wherein you are closing a particular day and opening the next day for data entry. After this process is completed and before any activity of the new accounting date begins, the following reports need to be taken.

Daily Report – This gives the total value of charges, insurance receipts, patient receipts, write offs and charge adjustments and the number of procedure units entered on a particular accounting date and the gross AR as on that date by doctor.

Production Report – This report shows the number of Demographics, Charge & Cash entered by data entry staff for the calendar date specified.

Month End Reports & Financials

When the activities for a particular month comes to an end, the month close has to be run. This is similar to the day close, the only difference being the reports. The following reports need to be taken.


Aged Accounts Receivable Summary – This report gives the total balance outstanding by patient type by age as at the end of the month.

Aged Accounts Receivable Detailed – This report gives the balance outstanding by patient type by age for each patient as at the end of the month.

AR Days Outstanding – This report shows what is the AR days for your project as at the end of the month. AR days shows how much of your daily charges constitutes the overall outstanding AR. For e.g. if the average charge per day for your specialty is $1000 and the Gross AR outstanding is $100K then your AR days is 100 days. The Average charge per day is calculated using the last three month’s charges.

Doctor Financials – This report gives you the total charges, insurance receipts, personal receipts, charge adjustments, insurance write off & change in AR for each doctor for the month or as on date based on the parameters you run the report.

Patient Type Financials – This reports gives you the total charges, insurance receipts, personal receipts, charge adjustments, insurance write off & change in AR for each patient type for the month or as on date based on the parameters you run the report.

Monthly Financials - This reports gives you the total charges, insurance receipts, personal receipts, charge adjustments, insurance write off & change in AR for each month.

The above reports are presented to the doctors after every month close. The figures depicted by these reports show the efficiency or otherwise of the billing office. The major criteria for assessing a billing office’s performance is high collections and low AR. If the reports show otherwise, then the billing office is onto problems which may result in termination of contract.

Common Terms used in financials:

a) Charges: This is the total value the amount billed for all tickets entered during the period.

b) Charge Adjustment: Charge adjustment in simple terms means adjustment to the charge amount billed. In certain circumstances, the doctors may give allowance to certain patients either because they are his/her colleagues in the hospital or relatives or relatives of his colleagues or may be friends.

The doctor makes a decision to waive his fees. This is called professional courtesy. This is removed from the

books by way of an adjustment. This may be a part of the amount billed or even the entire billed amount. The amount

shown in the financials is the total value of such charge adjustments made during the period.


c) Insurance write off: As explained in one of the sections earlier, insurance may not allow the entire amount billed by the provider. The difference between the amount allowed and the amount billed is the write off. This amount is reduced from the books. The amount shown in the financials is the total value of such insurance write off made during the period

d) Net Charges: Charges – Charge Adjustment – Insurance write off.

e) Balance Transfer: This is a term used when you transfer a patient to collections. When you perform this activity, you transfer the balance in the existing patient account to the collection account. This process is called balance transfer. The amount shown in the financials is the total value of such

balance transfers made during the period.

f) Personal Receipts: This gives the total amount of cash received from patients during the period.

g) Insurance Receipts: This gives the total amount of cash received from insurance carriers during the period.

h) Receipt Adjustments: Receipt adjustment in simple terms means adjustment to the receipt amount. This gives the total value of receipt adjustments made during the period.

i) Net Receipts: Personal Receipts + Insurance Receipts – Receipt Adjustments

j) Change in A/R: Net Charges + Balance Transfers – Net Receipts.

k) Gross AR: This figure gives the total amount outstanding as on date from insurance and patients.

In short this is equal to: Net Charges since inception + Balance transfers since

inception – Net Receipts since inception. (OR) Gross AR of the previous month + Change in AR of the

current month

l) Net Revenue: Gross Charges for the period x Expected %

m) Net AR: Net Revenue – Net Receipts.

n) Average Charges: Gross charges for past three months/3.


o) AR Days: This shows the number of days of charges still outstanding in books. This is calculated as:

Gross AR/Average Charges x 30. Average charges is calculated

using last three months’ charges.

p) Collection Rate: Net Receipts (Net Receipts + Charge Adjustments + Insurance Write offs)


Duties and Responsibilities

1. Scanning Department

2. Coding Department

3. Patient Demographic and Charges Department

4. Audit Department

5. Transmission Department

6. Cash Department

7. Analysis Department

8. Accounts Receivable Department

1. Scanning Department

Duties and responsibilities of the Scanning Department are as follows:

1. Scanning Person should be aware of fundamental functions of computer and should have thorough knowledge on Downloading and Uploading of Software like FTP Software, ACDSEE, etc.2. Thorough knowledge on process of downloading and uploading files and files extensions.3. Should know the functions of Printers, Scanning machine, Fax and should be

aware of rectifying miscellaneous problems. 4. Should be the first person to come into the office for printing the files and keep it for production people.5. Should check the E-mails and file control logs to be printed. 6. After downloading the files, files name and pages to be checked with the


Control Log.7. Printing Quality, Visibility, Printing Size to be checked8. After Printing the files, files to be handed over to related departments without any mismatch and signature from the department head should be obtained.9. After getting signatures, those sheets to be filed along with the Control Log.10. Should ensure that all the files are printed for the day and if there is any issue, same should be taken to the higher authorities for solving the same.11. If any pages missing or pages not visible or files missing or information required, mail to be sent to the Client office as well as to the related department heads.12. If there is any information to be scanned or faxed, should get it from the departments and finish the functions as per their instructions and to be finished within that day.13. After finishing all the process in the Scanning department, if the person has free time, should report to the manager for supporting/helping other departments.14. Scanning Person should complete the Day Log Sheet briefing the functions whatever they performed during that day.

2. Coding Department

Duties and responsibilities of the Coding Department are as follows:

1. Basically Coding Person should have in depth knowledge in Human Physiology and Human Anatomy.

2. Should have the knowledge of referring Current Procedure Terminology International Classification of Diseases (ICD), HCPCS Book, Modifiers, ASA Coding Book, etc.


3. Should have the knowledge of functions of various departments like Radiation Therapy, Anesthesia, Radiology, Pathology, Ambulatory Surgical Center, Ophthalmology, General Practice, etc. 4. Should have the thorough knowledge on functions of Coding Software. 5. Coding Person should maintain the control log with the details of File Name, pages, department, number of charges, etc. and the same should be regularly updated.6. Coding Person should complete all the files whatever they receive for coding for the day and there should not be any pending without any valid reasons. 7. If there is any pending due to errors in the charge sheet or not visible or any additional information required or wrongly mentioned in charge sheet, Coding person should send mail to the related department head stating the Information required.8. After finishing the day’s work, should prepare Day Log Sheet briefing the functions whatever they performed for the day.

3. Patient Demographic and Charges Department

Duties and responsibilities of the Patient Demographic and Charges Department are as follows:

1. Be aware of reading several Patient Demographic documents and information for entering into the system.2. Be able to read and enter American Names, City, State , Numbers and any additional information given in the Demographic Sheet.3. After getting the files from Scanning Department, file name and pages to be checked and quality of the printing also to be checked. 4. After entering Patient information in the system, entries should be checked Medical Billing Training Page 101 of 207

with the hard copies and files to be given for entering Charges.5. Charges Entry person should check the charge sheets and match with the details given in the Control Log6. Charge Entry Person should be aware of Billing Rules and the latest updates of their related departments. 7. Charges to be entered in the system following all rules and regulations with utmost care. There should not be any error or missing information in the charge entry otherwise there will be a problem or delay in receiving payments. 8. Whatever Charges Files received for the day, entries should be finished on that day itself and same entries should be checked with hard copies.9. After entering and checking the charges, files to be given to Audit Department for checking the charges once again before sending for Claims Transmission. 10. If there is any clarification, information required for entering Patient Demographics or Charges, should be kept in pending and mail to be sent to Department head and to Client Office immediately and mail to be kept in folder for back up purpose. 11. The Patient Demographics and Charges pending details should be updated in Excel sheet regularly and sent to Client Office.12. If the required information can be obtained from Coding, AR, Enrollment, mail to be sent to the related departments mentioning the requirements instead of disturbing Client Office.13. Any mail from Client or from other departments related to Patient Demographics or Charges should be immediately responded without


any delay. 14. Reports to be formatted in Word or in Excel as per Client’s requirement and the details to be sent regularly without fail.15. Charge Entry Person should keep the charges files in the proper racks and same should be kept in the good condition and retrievable condition.16. Charges File Directories in the system should be properly maintained and it should be easily accessible at any time.

4. Audit Department

Duties and responsibilities of the Audit Department are as follows:

1. Basically Audit person should be experienced in data entry process of Patient Demographic and Charges and should have thorough knowledge on Billing Rules and Regulations of Charges. 2. After receiving files from Charges department, details should be updated in the Excel Spread Sheet. 3. While checking Patient Demographic, audit person carefully check Name, Address, SSN, DOB, H Ph, W Ph, Policy ID, Coverage details, Subscriber Details, Employer details, etc.4. While checking Charges, audit person carefully check DOS, Procedure Code, Diagnosis Code, Modifier, Units, Value, TOS, POS, Ins Number, Doctor Number, Location, Prior Authorization, Referral, etc.5. If any error is found in the data or any data not entered in the system should be informed to the Charges department through mail for correction and the same information should be updated in the Excel Sheet for record purpose.


6. Audit Person should ensure that the charges department should finish corrections given by Audit department before sending claims through Transmission. 7. After auditing Patient Demographics and Charges Files, information like Entered by Whom, Entered date, # of charges, # of patients, correction details, audited by person ( name), audited date should be updated in the Excel spread sheet. 5. Transmission Department

Duties and responsibilities of the Transmission Department are as follows:

1. Transmission Department’s primary function is to transmit insuranceclaims through electronic and sending patient bills through electronic. 2. When the functions are through electronic and also when the third Party (i.e. Clearing House) also involves in this function, Transmission person should carefully follow the rules, regulations and process described by the Clearing House. 3. Transmission person should ensure that there is no claim rejection or batch rejections or any other rejections due to process errors or rules not followed or any manual error. If anything happens like that then there would be unnecessary rejections, explanations to the client, unnecessary time delay, etc. 4. Transmission person should keep clear proof of documents which shows the claims transmission details in the folder. Each and every time they have to take the printouts and keep in the folder as a back up on transmission of claims. 5. If the insurance denies the claims stating claims not filed in time, then we may have to take a copy of printouts with the transmission details and send the same to the insurance.


6. Transmission should maintain a control log mentioning the details of claims received for the day for transmission, details of patient bills received for the day for transmission, department details, number of claims transmitted, number of patient bills transmitted, Transmitted Date and Time, Claims Rejections, Patient Bill rejections, etc. 7. After transmitting claims or patient bills, mail to be sent to respectivedepartments confirming the transmission. There should not be any delay in transmitting claims, if there is any problem in transmission, immediately mail to be sent to respective departments or to Client’s Office stating the reasons.

6. Cash Department

Duties and responsibilities of the Cash Department are as follows:

1. After receiving files from Scan Department, Cash Person should check the # of pages, quality of the printing, etc. 2. Checks and EOB Copies to be separated and values to be compared between the Checks and EOB Copies. And also values given in the Log sheet should be compared with received Checks and EOB Copies. 3. If there is any discrepancy in receipt of files or in receipt of Checks and EOB Copies immediately mail to be sent to US office for clarification. 4. After checking checks and EOB copies, each related checks and EOB copies to be separately pinned and cash posting to be started5. Cash Poster should compare Claim# , Patient Name, DOS, Procedure, Units, Value, Policy ID in the EOB with details stored in the system. If everything matches with the system, then Amount Paid, Co-insurance, Deductible, Write off, Adjustment Amount and Patient Balance to be posted in the system.6. After posting all transactions into the system, printout to be taken and compared with the details and values given in the EOB.


7. Cash Posting is a major function in the Medical Billing, hence payment should be applied to the correct claim carefully. This will avoid unnecessary follow up by AR to the insurance and unnecessary time spending by AR analysts towards the paid claims. 8. If the payment is denied for any claims or payment is denied for any specific codes, same to be highlighted in the EOB Copy and information should be entered in the Patient Notes in the system. Then denied information should be given to AR people and analysts for analyzing and calling insurance for further action.9. Cash Person should finish all the cash files received for the day and there should not be any files pending. Because that will unnecessarily increase the work burden of AR people and AR analysts. 10. If there is any payment not posted in the system due to pages missing, wrong claim #, details not given clearly, patient not found, patient not in the system, not our payment, Pay to Address DOS not related to ours, etc. message to be sent to US office and AR people for the clarification and the same amount to be posted in the Unposted Account in the system. Details should be updated in the Excel Spread Sheet and regularly sent to US office. Once details are received and payment applied in the system, information should be removed from the Unposted List. 11. Normally Cash files will not be given for Audit, since it requires more time, more man power and cash process is an internal process and it does not lead to any violation of law like if any error made in charge entry that will lead to violation and cheating of US Law. So Cash Posting person should carefully apply the payments and other transactions in the system. 12. If the excess payment is received from Patient or from Insurance, excess


payments should be posted in separate account and checks and EOB copies should be kept separately. Excess payment details should be updated in Excel spread sheet and sent to US Office for further action. Once we get approval from US Office, immediately Refund Letter should be prepared and sent to US Office along with Check and EOB Copy. 13. Cash Person is responsible for tallying cash received from insurance and the cash applied in the system. At the end of every month, should tally monthly cash receipts with cash applied in the system. After tallying, reports should be sent to US Office. This is a very important process and based on these reports, US Office will proceed for funding activities.14. Cash person is responsible for analyzing small balances in the account. If the balance should be written off, then he/she should get written approval from department head and action to be taken. If the balance can be collected either from patient or insurance, then should guide AR to act on this. 15. Maintaining Cash files is a very important task in the Medical Billing. Because copies of checks and EOBs to be taken for sending Secondary claims, Patient Refunds, Insurance Refunds, Sending to Insurance, etc. So cash person should have log or any spread sheet which will contain the details of files and places where it is kept with full information. 16. Cash person should have thorough knowledge in preparing various reports in Excel or in Word. And also periodically, per clients request, reports should be sent to US office without fail. This will update the US office about collection and they would plan future activities based on the reports.


7. Analysis Department

1. Insurance Companies used to send Monthly Bulletins, Notices, Circulars, Denial EOB, EOB with Deductible and Co-insurance information, Billing Rule Modification, Procedure Changes, Diagnosis Changes, modifier changes, New Policies, Check Copies, etc. through mail. 2. The person who reads all the mails, should be aware of entire billing activities. So, analysis department used to take care of the receipt of those mails and act on that. After receiving these mails, mails would be sorted based on the information wise and entered in the excel spread sheet on the receipt of the day itself.3. After entering into the Excel spread sheet, Analyst should go through the records and start acting on that information. An analyst should be aware of fundamentals of patient demographics, charges billing rules, cash posting instructions, etc. 4. If there is any procedure change, diagnosis change, modifier change, etc. immediately mail to be sent to related departments stating the changes mentioned in the mail.

5. If there is any Policy Changes, New Circulars, Notices from Insurance, mail to be sent to respective departments and messages to be handed over to them. 6. If there is any claim denials, deductible, Co-insurance, patient balance, adjustments, write offs, etc. mentioned in the EOB, then the information


should be updated in respective patient accounts mentioning the claim numbers and all relevant details. 7. If any denial or rejection of procedure is due to the policy changes, change of procedure codes, change of rules, the information is common for entire entity, then the information should be sent to every body and action has to be taken commonly for all claims related to the changed procedures. 8. Analyst also should be aware of electronic claims rejection reasons, denial reasons and claims transmission formalities in order to avoid rejections. If there is any rejection , analyst should instruct charge people to correct for all claims and to avoid such corrections in future.9. AR Analyst fundamental job is to give work orders to AR people for calling insurance companies to get the information for charge and cash people and also to clear the pending accounts.10.Since Analysts are involved in insurance calling and maintaining accounts, their aim should be collecting more money from the insurance by following rules and regulations.11.Analyst should have close relationship with charges department and they should guide charges on the changes of procedures, diagnosis, units, modifiers, electronic or paper claims, correction of claims, coverage changes, etc. 12.Analyst should have target of analyzing number of accounts per day and giving number of accounts for AR People per day and they should work on completing the above task.


13.Whatever accounts given for calling insurance to be logged in Excel Spread sheet and instruction to be given to AR to update insurance Feed back. After they update information, next day Analyst should Check information given by AR and act based on that and try to Clear the balances of accounts. 14.Analyst’s primary responsibility is to keep the AR days maximum below 90 days and they work hard for reducing the days even more than that.15.Analyst should keep all the financial AR reports with them and they should have updated AR Balance information by patient type wise, doctor wise, day wise, claim wise to feed the Client office whenever they require. 16.Analyst should be able to co-ordinate with Charges Department, Cash Department, Night Calling Department, Department Heads and US Client Office.

8. Accounts Receivable Department

1. Accounts Receivable person is a person who co-ordinates with Patient Demographic , Charges , Auditing, Transmission, Cash , Analysis Departments. 2. Their primary function is to see that all departments are Functioning without any pending issues and they have to act as a link Between the departments and insurance companies. 3. Their main aim is to collect more revenue for the company by following with insurance Companies and giving clear information to insurance companies and To reduce the AR days towards the international standards.4. AR person should be polite , good communication, understanding Power, able to clear clarifications, able to get information from insurance,


able to have good official relationship with insurance representatives.5. They may have to call insurance companies for payment clarification,Denial clarification, address clarification, coverage clarification, policyclarification, etc. 6. If any information is globally applicable, then immediately they should correspond with entire department to apply the changes given by insurance and they should try to get documents from insurance. 7. AR person should have knowledge on Provider Enrollment process, Insurance Policy changes, Insurance payment terms, Insurance ClaimsAcceptance patterns, Insurance Calling timings, Insurance Claim RejectionReasons, etc. 8. AR person should not misuse phones for their personal use or for any other works other than official calls. This will spoil the company’s name as well as this will increase the cost for the company which will create troubles for other employees also. 9. After calling insurance as per the work orders given AR Analysis,AR person should update the information received from insurance in theExcel sheet and resend the same to Analysis department. 10. AR person should have a separate control log which contains number of accounts called per day, details of the patients, insurance , details received , etc.


Performance Appraisal

Normally the performance of the employees are appraised based on the following factors and measurements. This will be useful for salary revision and promotional activities.

Good Communication

Adequate Knowledge

Excellent Skills

Planning the work

Innovative Ideas

Adaptability techniques

Leadership Qualities

Dependability

Analysis Power

Adequate Productivity

Accuracy in Work

Responsibility Taking

Good Initiative


Developing Self Assessment

Commitment to the Work

Participation in Team Effort

Versatility

Developing Management Skills

Adaptation to the Situation, etc.

Based on the above, performance of the employee would be measured as Outstanding, Excellent, Very Good, Good, Average, Bad.


Importance of Meetings

Meetings allow you to exchange information and ideas and gives you the experience of working in a team. In the business world, Meetings enable management to draw on the ideas and expertise of staff, and to acknowledge the staff as valued members of a team.

Some advantages of involving in Meetings are:

Ideas can be generated.

Ideas can be shared.

Ideas can be 'tried out'.

Ideas can be responded to by others.

When the dynamics are right, groups provide a supportive and nurturing environment for academic and professional endeavor.

Group discussion skills have many professional applications.

Working in groups is fun!

There are several meetings used to take place in the office. Few are Group Meetings, Department Meetings, Meetings with the Client, Meetings with the Managers, etc. These are held every day or twice in a week or weekly once or any required situation.


The Meetings proceedings, information, decisions, ideas, suggestions, inquiries should be minuted without fail for future reference.

HIPAA Compliance

HIPAA is the Health Insurance Portability and Accountability Act of 1996.Section 264 of HIPAA includes administrative simplification provisions that require the implementation of national standards to regulate and protect electronically maintained or transmitted individual health information. The Health Insurance Portability & Accountability Act of 1996 (August 21), Public Law 104-191, which amends the Internal Revenue Service Code of 1986. Also known as the Kennedy-Kassebaum Act.

Improved healthcare delivery by standardizing the electronic data interchange for:

• patient health• administrative• financial• protects health data confidentiality and security:• sets and enforces standards (e.g.,unique identifiers for

individuals, employers, health plans, and healthcare providers)• sets security standards (e.g.,protecting confidentiality and integrity of individually identifiable health information)


What HIPAA will Accomplish

• Reduce administrative burden to providers and payers• Reduce administrative cost for providers and payers (a paper transaction costs anywhere from $5 to $15 compared to .$85 to $1.25 for an electronic transaction)• Create a national standard for electronic transactions enabling easier data sharing, record portability, and automated business processes• Speed financial transactions resulting in faster payment for services

Who is Affected?

“Covered Entities” include:

• Health Care Providers

Physicians, dentists, hospitals and “any other person who furnishes orbills and is paid for health care services or supplies in the normal courseof business”

• Health Plans

“An individual or group plan that provides, or pays the cost of, medicalcare,” including Medicare, state Medicaid plans, health insurance, healthmaintenance organizations, and other government-and-employer sponsoredplans

• Clearinghouses


“Billing services, re-pricing companies…and ‘value-added’ networks and switches…” And their... • Business Associates

“A person who on behalf of such a covered entity…performs, or assists inperformance of a function or activity involving the use or disclosure of individually identifiable health information”

“A contract between the covered entity and the business associate must establish the permitted and required uses and disclosures of such information by the business associate”

• All payers will have to accept and respond to HIPAA compliant electronic transactions.

• All providers who submit electronic transactions will have to do so in a HIPAA compliant format.

Information Covered by HIPAA

According to PL 104-191, section 1171, health information:

“relates to the past, present or future physical or mental health or condition of an individual; or the past, present or future payment for the provision of health care to an individual”

and is

“created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearing house”

Effective compliance will require organization-wide implementation. Steps will include:

Building initial organizational awareness of HIPAA

Comprehensive assessing of the organization's information security systems, policies and procedures

Developing an action plan with deadlines and timetables


Developing a technical and management infrastructure to implement the plan

Implementing a comprehensive action plan, including

o Developing new policies, processes, and procedures

o Building "chain of trust" agreements with service organization

o Redesigning a compliant technical information infrastructure

o Purchasing new, or adapting, information systems

o Developing new internal communications

o Training and enforcement

Now, we'll explore the next level of HIPAA - specifics that, for many of us, cause more confusion than clarity. Let's try to make "Administrative Simplification" simple!

HIPAA's "Administrative Simplification" provision is composed of four parts, each of which have generated a variety of "rules" and "standards." Many of the rules and standards are still in the "proposed" (by DHHS) stage; however, most are expected to become "final" rules within the year 2000. Even more confusing, the rules, when final, will often have different compliance deadlines.

The four parts of Administrative Simplification are:

I. Electronic Health Transactions Standards

II. Unique Identifiers

III. Security and Electronic Signature Standards

IV. Privacy and Confidentiality Standards

I. Electronic Health Transactions Standards

The term "Electronic Health Transactions" includes health claims, health plan eligibility, enrollment and disenrollment, payments for care and health plan premiums, claim status, first injury reports, coordination of benefits, and related transactions.


Today, health providers and plans use many different electronic formats. Implementing a national standard will mean we will all use one format, thereby "simplifying" and improving transaction efficiency nationwide. The proposed rule requires use of specific electronic formats developed by ANSI, the American National Standards Institute, for most transactions except claims attachments and first reports of injury. Proposed regulations for these exceptions are not yet out.

Virtually all health plans will have to adopt these standards, even if a transaction is on paper or by phone or FAX. Providers using non-electronic transactions are not required to adopt the standards; although if they don't, they will have to contract with a clearinghouse to provide translation services.

Health organizations also must adopt STANDARD CODE SETS to be used in all health transactions. For example, coding systems that describe diseases, injuries, and other health problems, as well as their causes, symptoms and actions taken must become uniform. All parties to any transaction will have to use and accept the same coding. Again, in the long run, this is intended to reduce mistakes, duplication of effort and costs. Fortunately, the code sets proposed as HIPAA standards are already used by many health plans, clearinghouses and providers, which should ease the transition.

II. Unique Identifiers for Providers, Employers, Health Plans and Patients.

The current system allows us to have multiple ID numbers when dealing with each other, which HIPAA sees as confusing, conducive to error and costly. It is expected that standard identifiers will reduce these problems.

III. Security of Health Information and Electronic Signature Standards

The new Security Standard will provide a uniform level of protection of all health information that is

1. Housed or transmitted electronically and that

2. Pertains to an individual.


In addition, organizations who use Electronic Signatures will have to meet a standard ensuring message integrity, user authentication, and non-repudiation.

The Security standard mandates safeguards for physical storage and maintenance, transmission, and access to individual health information. It applies not only to the transactions adopted under HIPAA, but to all individual health information that is maintained or transmitted. However, the Electronic Signature standard applies only to the transactions adopted under HIPAA.

The Security Standard does not require specific technologies to be used; solutions will vary from business to business, depending on the needs and technologies in place. Also, no transactions adopted under HIPAA currently require an electronic signature.

IV. Privacy and Confidentiality

The Final Rule for Privacy was published just as President Clinton was leaving office, on December 28, 2001. A paperwork glitch delayed notification of Congress, so the Congressional Review period didn't begin until February, pushing the effective date of the rule until April 14, 2001. DHHS Secretary Tommy Thompson used the time to solicit additional comments during March. DHHS received over 11,000 comments and plans to issue guidelines and clarification of the final rule in response. Compliance will be required on April 14, 2003 for most covered entities.

In general, privacy is about who has the right to access personally identifiable health information. The rule covers all individually identifiable health information in the hands of covered entities, regardless of whether the information is or has been in electronic form.

The Privacy standards:

Limit the non-consensual use and release of private health information;

Give patients new rights to access their medical records and to know who else has accessed them;


Restrict most disclosure of health information to the minimum needed for the intended purpose;

Establish new criminal and civil sanctions for improper use or disclosure;

Establish new requirements for access to records by researchers and others.

The new regulation reflects the five basic principles outlined at that time:

Consumer Control: The regulation provides consumers with critical new rights to control the release of their medical information

Boundaries: With few exceptions, an individual's health care information should be used for health purposes only, including treatment and payment.

Accountability: Under HIPAA, for the first time, there will be specific federal penalties if a patient's right to privacy is violated.

Public Responsibility: The new standards reflect the need to balance privacy protections with the public responsibility to support such national priorities as protecting public health, conducting medical research, improving the quality of care, and fighting health care fraud and abuse.

Security: It is the responsibility of organizations that are entrusted with health information to protect it against deliberate or inadvertent misuse or disclosure.

HIPAA Mandated Standards

Administrative SimplificationElectronic Data Transmission Data ProtectionTransactions Code Sets Identifiers Security Privacy

Electronic Transaction Benefits


Electronic transactions provide significant benefits compared with paper transactions

• Pre-edit for common errors• Reduce delays caused by scanning and re-keying• Accelerate delivery via secure networks• Provide positive acknowledgement of receipt• Eliminate costs of handling and storing paper documents

Electronic Transmissions Must Comply

All electronic transmissions from one computer to another plus all media including:

• Magnetic tape• Disk• CD -ROM• Internet transmissions• Intranets• Leased lines• Dial-up lines• Private networks

Time Limit for HIPAA Compliance

• If you do not comply with HIPAA transaction and code set guidelines, INSURANCE cannot accept or pay your claims.• If you do not submit your own claims, you must partner with a HIPAA compliant clearinghouse. INSURANCE cannot accept and pay your claims if your clearinghouse is not HIPAA compliant.• INSURANCE is encouraging all clearinghouses to become HIPAA compliant certified. It is your responsibility to make sure your clearinghouse vendor has a plan in place for HIPAA compliance. That plan should include certification.• Since this is a federal mandate all payers will have similar rules. Be sure to check with other payers including BCBS, Medicare, and others for details about their implementation and testing schedule.


Penalties for Non Compliance

HIPAA calls for severe civil and criminal penalties for noncompliance, including: -- fines up to $25K for multiple violations of the same standard in a calendar year -- fines up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information

Code of Conduct

1. In Time should be strictly followed.

2. Attendance should be signed Morning and Evening without fail

3. If there is any Swipe Card, should be used at the time of entering/leaving the office premises. It should be followed each and every time and the Swipe Card should be pinned in the dress.


4. If the Employee forgot to bring the Swipe Card, then the Temporary Card should be received from HR and used.

5. If the Swipe Card is lost, the Employee should inform HR for alternate Card.

6. If there is any delay in coming to office or need leave early to house, Permission Slip should be filled with reasons and department head signature should be obtained

7. If the Employee not able to come to Office in time due to Emergency situation, then he/she should inform the office over phone and after coming to the office Permission Slip should be filled and given.

8. If the Employee wants to take Leave then Leave Application Form should be filled before taking leave and department head signature should be obtained.

9. If the Employee taken leave without giving Leave Application due to Emergency situation, then the information should be given over phone and when he/she comes to office, leave application should be filled and given.

10. Dress Code should be strictly maintained. He/She should wear Formal dresses during week days and personality should be impressive.

11. Break Timings during Office Hours should be strictly followed as per the specifications given in the office.

12. Official E-mail should be used only for official purpose and passwords should not be informed to everybody.

13. Internet usage should be minimized and used for e-mail and browsing official sites.


14. Everyday work should be logged in the Sheets prescribed by office and same to be explained to the head of the department.

15. Personal Files, Unnecessary files which are not related to Office should not copied and kept in the Hard Disk of the system.

16. Instructions should be followed while using Xerox Machine, Printer , Scan and Fax Machines.

17. Working Table to be clean and it should not contain any unnecessary papers, books, etc. and all the required papers should be kept in the folders.

18. Files and Papers should be kept in the Rack or Cupboard as per the instruction from the Department Head.

19. Cleanliness to be strictly adhered in the office and other areas.

20. Friendly relationship should be maintained with the other colleagues.


Glossary of Billing and Medical Terms

ABN Advanced Beneficiary NoticeA form that a doctor or supplier should present to a Medicare beneficiary for signature before the service is provided whenever it is believed that Medicare may not pay for the ordered service. The form documents whether: (a) the patient agrees to pay for the service if Medicare refuses OR (b) the patient declines to have the test or service performed at all. Doctors and laboratories know which tests and services may not be covered because Medicare publishes limited coverage lists. (An ABN applies only if the patient has the Original Medicare Plan, not if the patient has a Medicare-managed plan.)

AdenocarcinomaA malignant neoplasm derived from epithelium.

AdjustmentFees and payments for medical services are sometimes modified based on contractual agreements between carriers and providers.

AKAAn abbreviation that means “also known as.” It is used in this glossary to indicate an alternate name for the word being defined; a synonym.

AntibodyA protein molecule which binds with a specific antigen and is part of the body’s defense mechanism against disease and infection. Antibodies may also be used in diagnostic and therapeutic efforts.

AntigenA protein, carbohydrate or other molecule capable of stimulating an immune response.

AspirateA body fluid (sampling of tissue) that has been removed from the body by negative pressure or suction. (See FNA)

AssignmentA process under which Medicare pays its share of the allowed charge directly to the physician or supplier. Medicare will do this only if the physician accepts Medicare's allowed charge as payment in full.

AutopsyA postmortem examination performed by a pathologist or medical examiner/coroner in order to determine the cause of death and study pathologic changes.

Beneficiary aka enrollee, member Someone who is eligible for or receiving benefits under an insurance policy or plan.

BenignThe description of an illness or tumor as being relatively self-limited or non-aggressive. Opposite of malignant.

Biopsy


The process of removing tissue surgically or by needle.

BladderA gas or fluid-filled sac; example: urine bladder.

Bone marrowThe soft tissue, located within the central portion of some bones, concerned with production of blood cells.

BronchialRelated to the upper respiratory tubes which carry air to and from the lungs.

BrushingsA cellular sample obtained by using small bristles at the end of a handle.

CellThe smallest structural unit of all plant and living organisms. Cells vary in size, shape and function. A delicate membrane encloses each cell. The genetic material of the cell is contained within the nucleus.

Cell blockA specimen produced from aspirates embedded within paraffin. The liquid specimen is spun down at high revolutions per minute (centrifugation) or filtered to separate cells from liquid. The cells packed at the bottom of the test tube (cellular “plug”) is then processed in paraffin much the same as a tissue specimen.

CodingHealth care services are identified and defined by specific alphanumeric abbreviations. (See CPT code and ICD-9 code) Consult/consultationMeeting of two or more physicians to evaluate the nature and progress of disease in a particular patient and to establish diagnosis, prognosis and treatment.

Core biopsyThe process of removing a specimen by means of a needle placed through the skin into the underlying tissue.

CPT code Current Procedural TerminologyA billing term for a standardized list of five-digit codes that designate the medical services delivered. The CPT codes are set, maintained and copyrighted by the American Medical Association (AMA) to describe procedures, services and supplies provided in the medical setting.

CryostatA freezing chamber used by pathologists to prepare fresh tissue sections for immediate microscopic evaluation/diagnosis.

CSF Cerebral Spinal FluidThe fluid which bathes the brain and spinal cord. A sample is sometimes obtained for analysis.

CystAn abnormal sac occurring in the body which contains gas, fluid or semi-solid material.

CytogeneticsThe branch of genetics concerned with the evaluation of chromosomes and their abnormalities.

Cytology


The microscopic study of individual cells.

Cytology, gynecologicCytology relating to women, primarily the genital tract as well as female reproductive physiology. (See Pap examination)

Cytology, non-gynecologicCytological examination of exfoliated (loose) cells is useful in diagnosing pre-malignant, malignant and other disorders. Common specimens for this evaluation include CSF (cerebrospinal fluid), breast, lung, joints, bladder washings, sputum and cysts.

Date of serviceThe date the health care services were provided to the beneficiary.

DecalcificationA step in the technical preparation of tissue rendering a hardened (calcified) tissue, such as bone or tooth, soft enough to cut into thin layers.

DeductibleThe amount of money the patient must pay toward medical bills in a calendar year before insurance begins to cover the costs of care. The dollar amount for the deductible varies according to the individual medical insurance plan. Contact your insurance carrier to determine if you have an annual deductible and how much it is.

Diagnosis code (See ICD-9 code)

DNA analysisThe measurement of DNA content is an important adjunct to traditional morphology in diagnosing, assessing prognosis and determining therapy in a wide variety of malignant diseases. It is of particular prognostic value in carcinomas of the breast, bladder, colon, cervix, lung, ovary, prostate, products of conception and the non-Hodgkin’s lymphomas.

EffusionsThe fluid which escapes from the blood vessels or lymphatic system into tissues or the body cavity.

EOB Explanation of BenefitsStatements mailed to a covered insured person and provider explaining how and why a claim was or was not paid. The Medicare version is called an EOMB (Explanation of Medical Benefits).

ERA Estrogen Receptor AssayThe evaluation of estrogen receptors in tissue used to assess treatment options or help in diagnosis.

FISH Fluorescent In Situ HybridizationA staining technique usually performed by the cytogenetics department in conjunction with chromosome analysis. Specimens tested are usually amniotic fluid, bone marrow, breast tissue and blood.

Flow cytometryAn analytical technique and department using computerization and optical light beams in a standardized, small glass chamber of known volume to count and measure individual cells. Flow Cytometry is used in three broad areas: (1) in the measurement of genetic material called DNA (2) immuno-phenotyping which is the evaluation of cell surface phenotypes (antigens) using monoclonal antibodies (3) hematology (blood studies).

FNA Fine Needle Aspiration


A technique where a lesion is entered by a small needle and a cellular sample is retrieved by suction (aspiration). The sample can then be reviewed by cytology or other means. FNA is a simple and reliable cytologic test which may be used in evaluation of palpable masses. An aspirate sample is smeared on a slide, stained, and reviewed by the pathologist. In many instances, an immediate diagnosis can be rendered, saving the patient a costly and time-consuming surgical biopsy.

FNA ClinicOur FNA Clinic is located in a laboratory setting on Swedish campus. Many physicians prefer to collect their patient’s FNA sample. In our FNA Clinic, WPC pathologists offer an added service of performing the FNA procedure (sample collection). When involved in the collection procedure, a pathologist provides an immediate evaluation of specimen adequacy. For more information, see our FNA Clinic section.Frozen sectionA thin slice of tissue cut from a frozen specimen. Usually the pathologist joins the surgical team in the Operating Room and then prepares the frozen section in a cryostat for immediate microscopic evaluation and to offer a preliminary diagnosis. Frozen sections provide the surgeon information which may be critical to both diagnosis and treatment.

Guarantor Party responsible for payment.

Gross examinationThe description of the physical characteristics of a specimen by manual examination before technical processing begins. The gross description is included in the pathology report. The sampling and preferred orientation of the specimen in its paraffin block is determined at this time.

Histochemical stain (See stains, immunohistochemistry)

HistologyThe science and practice that deals with preparation and microscopic study of cells in tissues and organs in relation to their anatomy and disease.

ICD-9 code International Classification of Diseases, 9th RevisionAn established numerical classification system is used by health care professionals to describe the diagnosis. The diagnosis code submitted by the provider explains to insurance carriers why the procedure, service, supplies or medical encounter was ordered. The diagnosis code is part of the medical claim submitted to insurance carriers for payment. Sometimes the codes provided to our laboratory are incomplete or invalid. Diagnosis coding is complicated. If an insurance carrier denies payment for a coding reason, the patient should contact the physician’s office. The office will clarify the diagnosis to our billing department.

Immunocytochemistry aka ICC (See immunohistochemistry)

Immunofluorescence testingImmunofluroescent antibody testing is divided into Direct (performed on skin biopsy specimens) and Indirect (performed on serum). Specific antibodies react with specific tissue components. Immunoglobulins and/or complements (autoantibodies) become visible to the pathologist by reacting tissue sections of fresh and/or cryostat-frozen biopsies. The slide specimens are examined microscopically for specific immunofluorescence using a fluorescence microscope. Among other applications this technique may be used to evaluate a variety of autoimmune conditions such as lupus and arthritis.

Immunohistochemistry aka IHC, immunocytochemistry.A special field of histology which uses antibodies to detect antigens within tissue. IHC is a laboratory technique which has dramatically improved the ability of pathologists to sub-classify


http://washingtonpathology.com/pages/services.htm#FNA

benign and malignant cells and differentiate between various types of diseases.

Immunophenotyping aka cell surface marker studiesThe analysis of cell surface antigens is performed in the Flow Cytometry Department using monoclonal antibodies. This technique has diagnostic, prognostic and therapeutic importance for many conditions. For example, this technique is utilized to evaluate immunodeficiency diseases (hereditary and acquired) as well as to distinguish and classify lymphomas and leukemias.

Insurance, healthMedical coverage by contract that guarantees payment of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.

Insurance, primaryThe first medical plan that pays patient expenses, under coordination of benefits rules.

Insurance, secondaryA health policy that pays costs after primary insurance, under coordination of benefits rules; any insurance that supplements primary coverage. The secondary insurance contracts reduce the patient’s direct costs.

Interpretation aka “interp” on our invoiceThe pathologist’s professional assessment of a case based on the attending physician’s clinical findings in conjunction with microscopic pathology. The report is sent to the ordering physician.

Invoice aka statement, billThe form sent by a health care provider charging for services rendered.

LavageThe washing out of a hollow structure such as the bronchial tree.

LeukemiaA neoplastic proliferation of white cells (leukocytes).

Limited Coverage TestsMedicare limits payment for certain tests based on the frequency the test is ordered and whether or not a patient’s diagnosis meets Medicare’s insurance criteria. If Medicare may not cover the cost of the service because of limited coverage, the patient must be informed in advance of service with an opportunity to discuss patient choices and the ABN form. (See Advanced Beneficiary Notice)

MalignantA property of tissues characterized by uncontrollable growth with possible invasion of normal tissues and/or metastasis.

MedicaidA program financed jointly by the federal government and the states, that provides health coverage for mostly low income women and children as well as nursing home care for low-income elderly. Levels of funding and benefits and the portion of low-income people covered vary widely from state to state.

MedicareThe federal program providing health insurance for people aged 65 and older and for disabled people of all ages. Medicare Part A covers hospitalization and is a compulsory benefit. Medicare Part B covers outpatient services and is a voluntary service.


Monoclonal antibodiesA protein, which is specific for certain antigens formed by a single clone (population) of cells. Used in the medical industry for research, diagnostics and treatments.

Needle biopsy (See core biopsy)

NeoplasmAn abnormal tissue that grows by cellular proliferation and usually forms a distinct mass of tissue sometimes referred to as a tumor. This behavior of the cells may be either benign or malignant.

NeuropathologyA subspecialty of pathology relating to the diseases of the brain, spinal cord, peripheral nerves and muscles.

Pap examinationThe microscopic evaluation of a cytology specimen for cancer detection and diagnosis, usually in reference to cervical cancer screening in women. The “Pap” technique was named after George Papanicolaou, inventor of the Pap smear, stain and examination. Papanicolaou (PAP) staining of endocervical, ectocervical and vaginal smears is an important aspect of women’s health care. Specimens in this category include traditional Pap smears as well as thin-layer (liquid-based) Pap specimens. (See cytopathology, gynecological)

PathologistPathologists are specialty trained physicians. They are doctors of medicine who practice chiefly in a medical laboratory setting. Pathologists serve as consultants to their clinical colleagues in the following ways: make diagnoses on anatomic tissue, guide physicians in test selection, manage medical laboratories and interpret laboratory tests. They serve as educators for the hospital staff and are referred to as “the doctor’s doctor.” Human pathology is a medical specialty requiring a medical degree and residency training in one or both branches of pathology (anatomic and clinical) or their subspecialties, as approved by the American Board of Pathology.To become a pathologist a medical graduate must serve a five-year residency incorporating the major disciplines of anatomic and clinical pathology. Anatomic pathology encompasses surgical pathology, cytology and autopsy pathology. Clinical pathology includes all of the functions performed in the analytical work of the clinical laboratory such as hematology, chemistry, blood banking and microbiology.

Post-graduate Ph.D. degrees are available for those individuals who are interested in detailed study of disease processes and concentration on experimental pathology. Additional (subspecialty) board certifications exist for those pathologists who specialize and include such fields as: Clinical Chemistry, Cytopathology, Dermatopathology, Forensic Pathology, Hematopathology, Immunopathology, Neuropathology to name a few.Pathologists’ assistantA Pathologists’ Assistant (PA) is an intensively trained health professional who provides anatomic pathology services under the direction and supervision of a pathologist. Pathologists’ assistants interact with pathologists in the same manner that physicians’ assistants carry out their duties under the direction of physicians in surgical and medical practice. Pathologists’ Assistants, though they do not diagnose, are an integral part of the anatomic pathology team. The PA’s contribute to the overall efficiency of the pathology practice in a cost effective manner by performing a variety of tasks, consisting primarily of gross examination of surgical pathology specimens and performance of autopsies.

The American Association of Pathologists' Assistants (AAPA) is the world's only professional organization for pathologists' assistants. Members of the AAPA have met educational and training requirements, maintain professional standards defined in the Code of Regulations and have passed the Fellowship examination.


The spectrum of ancillary activities performed by PA’s is large and influenced by different types of work settings. Following is short list of tasks that this valued member of the professional staff, qualified by their advanced academic and practical training, may perform:•

Assist and/or perform the examination of surgical and postmortem specimens.

•

Supervise appropriate specimen accessioning and handling.

•

Describe macroscopic anatomic features.

•

Photograph specimens and microscopic slides as directed by a pathologist.

•

Dissect and prepare tissues for processing.

•

Confer with the pathologist regarding special techniques, stains and studies.

For more information: please refer to the AAPA website: www.pathologistsassistants.orgPathology, anatomicThe subspecialty of pathology that pertains to physical (gross) and microscopic study of organs, tissues and fluids removed for biopsy or during postmortem examination.

Pathology, clinicalThe subspecialty of pathology that deals with the theoretical and technical aspects (methods, procedures and interpretations) of automated and manual clinical testing such as chemistry, hematology, microbiology, serology, etc.

PRA Progesterone Receptor Assay.The evaluation of progesterone hormone receptors in tissues. May be used to assess diagnosis and treatment options.

PremiumAmount of money paid toward the purchase of health insurance benefits.

Professional FeeIn pathology billing, the professional fee represents the pathologist’s involvement with the case: • gross examination and evaluation of frozen sections (intra-operative consultation)

• review of all slides including consultations

• interpretation of the findings (including special stains that might be ordered)

• composition of a report for the attending clinician. Technical and Professional services are billed separately. Different providers perform these two services.

PrognosisA forecast of the probable course or outcome of a disease.

ProviderAn individual or institution that provides medical services (e.g. a physician, hospital or laboratory). This term should not be confused with an insurance company that "provides" insurance. Generally, the entity that provides the service is the entity that submits the bill.

SarcomaA tumor derived from certain tissues; usually malignant.


http://www.pathologistsassistants.org/

Second opinion (See consult)

SlideA thin glass plate on which a 3-4 micron thick tissue section is placed or a liquid specimen is smeared for microscopic examination.

SmearA slide preparation of a liquid or semi-liquid medical specimen to be used for microscopic study.

SputumA specimen collected from the air passages by coughing.

StainA laboratory technique in which chemicals are used to color and dye tissues and cells. As tools for the pathologists, many stains have specific uses for diagnosis.

Stains, immunoperoxidaseThese stains became available to pathologists during the 1980’s. They have revolutionized the practice of diagnostic pathology as well as opened new insights into basic research. These stains are usually monoclonal (sometimes polyclonal) antibodies, which are antibodies raised against specific proteins and amplified by cloning. The antibodies are then labeled with a marker which produces brown or red cellular colors. Depending upon the antibody used and the tissue which is stained, the pathologist may use these stains to narrow a differential diagnosis or confirm an initial impression.

Stains, routine (traditional)The routine stain for tissue sections is the H and E (Hematoxylin and Eosin). This stain has stood the test of time for nearly the entire 20th century. Hematoxylin stains tissue a deep blue while eosin stains a deep red. Depending upon the tissue, all cells are composed of a nearly infinite combination of the various hues and shades of these two stains. Most cells have a reproducible staining pattern, regardless of the tissue. For example, cell nuclei usually are deeply blue (or basophilic); squamous cells, such as those comprising the skin, are usually red (or eosinophilic).

Stains, specialThere are usual special stains and there are immunoperoxidase special stains. The usual special stains are based on less specific chemical reactions and may be useful to the pathologist for diagnoses.

Technical ComponentThe technical staff of the laboratory prepares the patient’s pathology specimen for review by a pathologist. The technical process may include any or all of the following steps: • Inspect and describe the intact specimen (gross examination) for physical characteristics

• Proper position of the specimen in the paraffin block

• Fixation of the specimen in alcohol or formaldehyde to preserve the tissue

• Decalcify to make hard bone and/or teeth soft enough to section

• Dehydrate and infiltrate the specimen with paraffin (wax) to prevent cellular alteration

• Embed the specimen into a small, paraffin block to keep the specimen secure

• Cut the block into thin sections

• Place the sections onto glass microscope slides

• Stain the slides for professional review and interpretation

• Prepare special stains and immunohistochemical studies


Technical and Professional services are billed separately. Different providers perform these two services.

Thin-layer Pap (See cytology, gynecologic)

Tumor (See neoplasm)WashingsA cellular sample obtained by flushing a body area with fluid.Medical Claims Glossary

Actual Charges The amount a physician or supplier actually bills a patient for a medical service, product or supply. Allowable Charges Limit of payment for a Medicare approved service. Approved Charges Dollar amount that Medicare will allow for the billed service. Assignment When a physician or other health care provider agrees to accept as payment in full Medicare's prevailing charge and does not bill the patient for any difference in cost between Medicare's payment and the physician's fee. Cap A point at which benefits cease, a ceiling or maximum. Coordination of Benefits A method of integrating benefits payable under more than one insurance plan so that the insured’s benefits from all sources do not exceed 100% of the client's available medical expenses. Customary Charge Amount most frequently billed by a provider within the last year of any particular service. Electronic Claims ProcessingExplanation of Benefits (EOB) Determination on how your claim was paid issued by the insurance company to the insured and provider of service. Explanation of Medicare Benefits (EOMB) Explanation of Medicare Benefits from Medicare carrier indicating the level of benefits paid. Out of Pocket Expense The insurance term for the insured s co-payment and deductible. Participating Physician A physician or supplier who agrees to accepts assignment on all Medicare Claims. Reasonable Charge Amount approved by Medicare which will be either the customary charge, the prevailing charge or the actual charge - whichever is the lowest. Usual and Customary The amount an insurance company has determined is the upper limit it will pay for a particular procedure in your zip code area.

Billing and Insurance Glossary Terms Activities of Daily Living (ADLs) - Daily routine of self-care activities such as dressing, bathing and eating. Allowed Expenses - The maximum amount a plan pays for a covered service. See Usual and Customary Charges. Ambulatory Care - Medical services provided on an outpatient (non-hospitalized) basis (APC) Ambulatory Patient Classifications - A structure for classifying outpatient services and procedures for purposes of payment.


Assignment - A process under which Medicare pays its share of the allowed charge directly to the physician or supplier. Medicare will do this only if the physician accepts Medicare's allowed charge as payment in full. Balance Billing - The practice of billing patients for all charges over the physician rate paid by insurers. Many managed care plans prohibit this practice. Benefits - These are medical services for which your insurance plan will pay, in full or in part. Beneficiary - Someone who is eligible for or receiving benefits under an insurance policy or plan. Children's Health Insurance Program (CHIP) - A federal program jointly funded by states and the federal government, which provides medical insurance coverage for children not covered by state Medicaid-funded programs. Claim - A notice to the insurance company that a person received care covered by the plan. A claim is also a request for payment.Coding - How physician's services are identified and defined. Co-insurance - A type of cost sharing where the beneficiary and insurance provider share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, for Medicare physicians' services, the beneficiary pays co-insurance of 20 percent of allowed charges. Consolidated Omnibus Budget Reconciliation Act (COBRA) - A federal law that requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated. Applies to employers with 20 or more eligible employees. Typically, COBRA makes continued coverage available for up to 18 or 36 months. COBRA enrollees may be required to pay 100 percent of the premium, plus an additional 2 percent.Coordinated Coverage - Integrating benefits payable under more than one health insurance (for example, Medicare and retiree health benefits). Coordinated coverage is typically arranged so the insured benefits from all sources not exceding 100 percent of allowable medical expenses. Coordinated coverage may require beneficiaries to pay some deductible or co-insurance. Coordination of Benefits (COB) - A provision that applies when a person is covered under more than one group medical program. (See "Coordinated Coverage" above.) Co-insurance - A term that describes a shared payment between an insurance company and an insured individual. It's usually described in percentages; for example, the insurance company agrees to pay 80% of covered charges and the individual picks up 20%. Co-payment - A fixed dollar amount paid for a covered service by a beneficiary; amount that a member of a health plan has to pay for specific health services, such as visits to a physician. Coverage - What services the health plan does and does not pay for.Covered Expenses - What the insurance company will consider paying for as defined in the contract. For example, under some plans generic prescriptions are covered expenses while brand name prescriptions are not.Date Of Service (DOS) - The date(s) healthcare services were provided to the beneficiary.Deductible - A portion of the covered expenses (typically $100, $200 or $500) that an insured individual must pay before insurance coverage with co-insurance goes into effect. Deductibles are standard in many policies, and are usually based on a calendar year.Diagnosis-Related Groups (DRGs) - The hospital classification and reimbursement system that groups patients by diagnosis, surgical procedures, age, sex and presence of complications. This is a financing mechanism used to reimburse hospital and selected other providers for services rendered.Duplicate Coverage Inquiry (DCI) - A request to an insurance company or group medical plan by another insurance company or medical plan to find out whether other coverage exists (see Coordinated Coverage).Durable Medical Equipment (DME) - Medical equipment which: can withstand repeated use; is not disposable; is used to serve a medical purpose; is generally not useful to a person in the absence of sickness or injury, and is appropriate for use in the home. Examples include hospital beds, wheelchairs and oxygen equipment.


Employee Retirement Income Security Act of 1974 (ERISA) - This law mandates reporting, disclosure of grievance and appeals requirements and financial standards for group life and health. Self-insured plans are regulated by this law.Enrollee - person who is covered by health insurance.Exclusive Provider Organization (EPO) - Arrangement consisting of a group of providers who have a contract with an insurer, employer, third party administrator or other sponsoring group. Criteria for provider participation may be the same of those in PPOs but have a more restrictive provider selection and credentialing process. Experimental Procedures - Any health care services, that are determined by the insurance plan to be either; not generally accepted by informed health care professionals in the United States as effective in treating the condition, illness or diagnosis for which their use is proposed; or not proven by scientific evidence to be effective in treating the condition for which it is proposed. Explanation of Benefits (EOB) - the coverage statement sent to covered persons listing services rendered, amount billed and payment made. This normally would include any amounts due from the patient, as described in "Beneficiary Liability," "Co-insurance," "Deductible" and "Co-payment" all listed above.Health Care Provider - an individual or institution that provides medical services (e.g. a physician, hospital or laboratory). This term should not be confused with an insurance company that "provides" insurance.Health Insurance - Coverage that provides for the payment of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.Health Insurance Portability and Accountability Act (HIPAA) - A federal law intended to improve the availability and continuity of health insurance coverage that, among other things:places limits on exclusions for pre-existing medical conditions; permits certain individuals to enroll for available group healthcare coverage when they lose other health coverage or have a new dependent; prohibits discrimination in group enrollment based on health status; guarantees the availability of health coverage to small employers and the renewability of health insurance coverage in the small and large group markets; requires availability of non-group coverage for certain individuals whose group coverage is terminated. Health Maintenance Organization (HMO) - an entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium.Hospital Inpatient Prospective Payment System (PPS) - Medicare's method of paying acute care hospitals for inpatient care. Prospective per-case payment rates are set at a level intended to cover operating costs for treating a typical inpatient in a given DRG.International Classification of Diseases, 9th Edition (Clinical Modification) (ICD-9-CM) - a listing of diagnosis and identifying codes used by physicians and hospitals for reporting diagnoses and procedures of health plan enrollees.Maximum Out of Pocket - The most money you can expect to pay for covered expenses. The maximum limit varies from plan to plan. Once the maximum out-of-pocket has been met, the health plan will pay 100% of certain covered expenses.Medicaid - (1) A state/federal benefit program for the poor who are aged, blind, disabled or members of families with dependent children. Each state sets its own eligibility standards. Only 40% of individuals with income below the poverty level currently are covered.Medicare - A federal health benefit program for people over 65 and disabled that covers 35 million Americans - or about 14% of the population - for an annual cost of over $120 billion. Medicare pays for 25% of all hospital care and 23% of all physician services.Medicare Supplement Policy (Medsupp) - the insurer will pay a policyholder's Medicare co-insurance, deductible and co-payments for Medicare Part A and B and may provide additional supplement benefits according to the supplement policy selected. Also called Medigap of Medicare wrap.Medigap Insurance - privately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare


deductibles, co-insurance and balance bills, as well as payment for services not covered by Medicare.Medigap Plan - purchased by Medicare enrollees to cover co-payments, deductibles and healthcare goods or services not paid for by Medicare. Also known as a Medicare supplements policy.Medigap Policy - a privately purchased insurance policy that supplements Medicare coverage.Network - Physicians, hospitals, and other health care providers that an HMO, PPO or other managed care network has selected to provide care for its members.Non-Participating Provider (Non-par) - Also known as out-of-network provider. A healthcare provider who has not contracted with the carrier of a health plan to be a participating provider of health care.Open Enrollment - A specified period of time in which employees may change insurance plans and medical groups offered by their employer and have the new insurance effective at a later date.Out of Network (OON) - coverage for treatment obtained from a non-participating provider. Typically, it requires payment of a deductible and higher co-payments and co-insurance than for treatment from a participating provider.Out-of-Pocket-Costs/Expenses (OOPs) - The portion of payments for covered health services required to be paid by the patient, including co-payments, co-insurance and deductible. (See "Beneficiary Liability," "Co-insurance," "Deductible" and "Co-payment" above.)Over-the-Counter Drug (OTC) - a drug product that does not require a prescription under federal or state law.Pre-Admission Certification (PAC) - a review of the need for inpatient hospital care, completed before the actual admission.Participating Provider - A provider who has contracted with the health plan to deliver medical services to covered persons. The provider may be a hospital, pharmacy or other facility or a physician who has contractually accepted the terms and conditions as set forth by the health plan. Part A Medicare - Medical Hospital Insurance (HI) under part A of title XVIII of Social Security Act, which covers patients for inpatient hospital, home health, hospice and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and co-payments.Part B Medicare - Medicare Supplement Medical Insurance (SMI) under Part B of Title XVII of the Social Security Act, which covers Medicare beneficiaries for physician services, medical supplies and other outpatient treatment. Beneficiaries are responsible for monthly premiums, co-payments, deductibles and balance billing.Point-of-Service Plan (POS) - Managed care product that offers enrollees a choice among options when they need medical services, rather than when they enroll in the plan. Enrollees may use providers outside the managed care network, but usually at higher cost. (This should not be confused with POS as used in retail pharmacy, where it stands for point of sale.)Preauthorization - An insurance plan requirement in which you or your primary care physician need to notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense.Pre-certification - Authorization given by a health plan for a Member to obtain services from a health care provider, most commonly required for hospital services. Members should refer to their insurance identification card or call their health plan to obtain information regarding pre-certification requirements.Pre-existing Condition (PEC) - Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage. Pre-existing conditions may not be covered for some specified amount of time as defined in the certificate of coverage (usually six to 12 months). Individuals can be required to satisfy a pre-existing waiting period only once, so long as they maintain continuous group health plan coverage with one or more carriers.Pre-existing Condition Exclusion - A practice of some health insurers to deny coverage to individuals for a certain period for health conditions that already exist when coverage is initiated.Preferred Provider Organization (PPO) - A program that establishes contracts with providers of medical care. Providers under such contracts are referred to as a preferred


provider. Usually, the benefit contract provides significantly better benefits and lower member costs for services received from preferred providers, thus encouraging covered persons to use these providers.Premium - Amount paid periodically to purchase health insurance benefits. Prevailing Charge - What determines a physician's payment for a service under the Medicare payment system.Primary Care Network (PCN) - A group of primary care physicians who have joined together to share the risk of providing care to their patients who are covered by a given health plan.Primary Care Physician (PCP) - A physician, the majority of whose practice is devoted to internal medicine, family/general practice and pediatrics. An obstetrician/gynecologist sometimes is considered a primary care physician, depending on coverage.Reasonable Charge - A fee is considered "Reasonable" if it is both usual and customary or if it is justified because there is a complex problem involved. Referral - Approval or consent by a primary care physician for patient referral to ancillary services and specialists. Secondary Insurance - Any insurance that supplements Medicare coverage. The three main sources for secondary insurance are employers, privately purchased Medigap plans and Medicaid.Single Payer - Government-paid health care (often called "socialized medicine") using tax dollars. Skilled Nursing Facility (SNF) - A facility, either free-standing or part of a hospital, that accepts patients seeking rehabilitation and medical care that is less intense than that received in a hospital.Specialist - A physician who specializes in a specific area of medicine, such as cardiology, oncology, urology, etc. Most HMOs require members to obtain a Referral from their Primary Care Physician before setting an appointment to see a Specialist.Sub-Acute Care - Usually described as a comprehensive inpatient program for those who have experienced a serious illness, injury or disease, but who do not require intensive hospital services. The range of services considered sub-acute can include infusion therapy, respiratory care, cardiac services, wound care, rehabilitation services, post-operative recovery programs for knee and hip replacements, cancer, stroke and AIDS care.Subscriber - The person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO or other health plan.Third Party Administrator (TPA) - An independent person or corporate entity (third party) that administers group benefits, claims and administration for a self-insured company or group.Usual, Customary and Reasonable (UCR) - A term used to refer to the commonly charged or prevailing fees for health services within a geographic area.Utilization Review (UR) - Programs designed to reduce unnecessary medical services, both inpatient and outpatient. Utilization reviews may be prospective, retrospective, concurrent, or in relation to discharge planning.

Sample ReportsDaily Log Call ReportThis report lists the name, address, locations, run type and charges for each patient we have entered for you the previous month. This will also list the total charged out the previous month. (WORD FORMAT .DOC)Credit Detail ReportThis report lists the name, call date, schedule, event, code, credit date, and total dollar amount for payments posted the previous month. This will also summarize the payments by type and payment source. (WORD FORMAT .DOC)Adjustment Report with SummaryThis report illustrates any write off's we processed for the previous month, as well as contractual adjustments we made for various insurance carriers. This is listed in detail and summarized at the end of the report. (WORD FORMAT .DOC) There are a number of reports available not listed here and Medicount has the availability to custom design any report needed by the City.


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Frequently Asked Billing Questions

Medical billing is a complex system even for those who deal with it every day. There are so many insurance carriers and so many insurance contracts. Each contract has its own terms and the terms of coverage may vary from patient to patient. Added to the confusion is that a person’s carrier might change with a change in circumstance. For example, an employer may change carriers, the patient may have a change in employment and some people have both primary and secondary insurance coverage. To assist in the interpretation of our invoice and for patient convenience we have published definitions of words and terminology in our Patient Glossary.

Following are answers to our most frequently asked billing questions.

Q: Who are you? A: Our group of pathologists is physically located on Swedish Medical Center campus in Seattle, WA. Our physicians, board certified in the specialty of pathology, provide professional laboratory support to health care providers at Swedish Medical Center, in managed care organizations, in private practices as well as at public clinics. Pathologists evaluate Pap smears, lab tests, biopsy and surgical specimens for attending health care providers.

Q: What is this bill for?A: A tissue or body fluid obtained at either a doctor’s office or Swedish Medical Center and labeled with your name was submitted to the laboratory for evaluation. Our pathologists are the specialists who evaluate the pathology specimen and consult with your doctor as to whether the sample submitted contains any abnormality. (see Glossary, Technical Component and Professional Fees)

Q: Which doctor sent this invoice? A: The physician who referred your case for professional evaluation is referenced on the WPC invoice (monthly statement).


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Q: What is an “EOB”?A: EOB stands for Explanation of Benefits. The insurance company sends the patient and the provider a form summarizing the insurance plan’s coverage for a specific medical event (procedure, test or supplies). Q: Why didn’t you bill my insurance? A: There are several explanations why you might receive a bill even though you have medical coverage:•

Perhaps our billing department did not receive the complete insurance information or patient details for us to submit a claim.

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Sometimes the insurance carrier has been billed but the payment was denied. If a denial is the cause of your receiving a bill from WPC, please refer to the EOB (Explanation of Benefits) mailed by your insurance company. The EOB form states the reason(s) for denial.

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If you are a Medicare patient, it is possible that payment for a Limited Coverage Test was denied. In those instances, the patient is responsible for the charges whenever the patient has signed the Advanced Beneficiary Notice before the specimen was collected.

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If you wish to submit billing information directly to our billing office, please phone or fax our Billing Department.

Q: What does “deductible” mean? A: The deductible is the amount of money in a calendar year that the patient must pay before the insurance will start paying. The amount varies according to the contractual terms of the individual insurance policy. Q: My Pap smear was reported as “Negative” yet it was reviewed by a pathologist. Why was it reviewed by a pathologist and why was I, as the patient, not informed of additional evaluation and additional charges?A: Many pap slides are interpreted in the initial screening to contain reactive or reparative changes, atypical cells of undetermined significance, or to be in premalignant or malignant categories. CLIA ’88 Regulations (as published in the Federal Register, Vol. 57, No. 40, February 28, 1992, Section 493.1257, Paragraph c:1) mandate that these conditions be evaluated by a pathologist. The initial screening of a pap smear is considered part of the Technical Component. A Pathologist’s Review of a Pap smear is not considered additional testing but is, rather, a continuation of the original pap evaluation as requested by the healthcare provider and does not require notification to the patient. Sometimes the initially suspected condition results in a “Negative” report as determined by the pathologist. There is an additional charge for the Pathologist’s Review because it is considered a professional consultation and as such is an independent and different procedure code (CPT code) from the technical component. The Pathologist’s Review of a pap smear is considered a Professional Fee. The Professional Fee may be billed separately from the original screen by a cytotechnologist.Advance notice to a patient of a required Pathologist’s Review is impossible because conditions requiring review are not determined until the initial screening of a pap smear.


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Billing Guide

INTRODUCTIONThis billing guide represents answers to the most frequently asked questions about reimbursement for imaging agents used in association with Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computed Tomography (CT) scans, and scintigraphic imaging.

The guide is divided into eight sections:

Insurance Overview;

Coding Systems;

Magnetic Resonance Coverage and Payment Policies;

Coding and Claims Submission for Magnetic Resonance Studies;

Coverage and Payment Policies for Diagnostic Radiology Studies Using Low-Osmolar Contrast Material (LOCM);

Coding and Claims Submission for LOCM Studies;


Coverage and Payment Policies for Nuclear Medicine; and

Coding and Claims Submission for Nuclear Medicine.

The information contained in this guide is for informational purposes only and should not be construed as legal advice.As with all paramagnetic agents, gadopentetate dimeglumine injection is not indicated for MRA.

INSURANCE OVERVIEWMost patients undergoing diagnostic radiology procedures are eligible for health benefits under one or more third-party payers. Below we present an overview of the major public and private insurers and their general coverage and reimbursement policies for diagnostic radiology procedures.

PAYERSMedicareMedicare is a federal health insurance program for the elderly, disabled and persons with end-stage renal disease. In general, Medicare covers diagnostic radiology procedures and imaging agents when they are considered reasonable and necessary for the diagnosis or treatment of an illness or injury. However, Medicare has developed specific coverage and coding policies for paramagnetic contrast materials, like gadopentetate dimeglumine injection and ferumoxides injectable solution, low-osmolar contrast materials (LOCM), like iopromide injection, and nuclear medicine imaging agents such as kits for the preparation of Technetium Tc 99m depreotide injection and kits for the preparation of Technetium Tc 99m apcitide injection.Medicare makes payment determinations for diagnostic radiology procedures and imaging agents based on where the procedure is performed. More specifically, Medicare uses different payment methodologies for procedures performed in a hospital outpatient department versus a freestanding imaging center.

Private InsurersPrivate insurers — which include Blue Cross and Blue Shield (BC/BS) plans, commercial insurers, and various managed care plans — provide health insurance coverage through group policies offered by employers and through contracts with individuals. Benefits vary tremendously from company to company, and from contract to contract. Generally, Blue Cross plans provide coverage for basic benefits (inpatient hospital and other medical and surgical services); Blue Shield plans offer coverage for major medical and surgical (catastrophic) care and outpatient services. Commercial insurers frequently are subsidiaries of major life insurance companies like Aetna and CIGNA. Managed care plans such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) are designed to control medical expenditures. Patients with managed care benefits usually are restricted to a smaller network of providers or receive better benefits if they use a preferred provider. Private insurers reimburse physicians and facilities using a variety of methods including capitated fees, discounted charges, fee schedule similar to Medicare’s Resource-Based Relative Value Scale (RBRVS), and per diems.

MedicaidMedicaid is a joint federal-state matching program designed to provide health insurance to low-income individuals. Because eligibility requirements are set by the states, Medicaid benefits vary tremendously by state.

SETTINGS OF CAREFreestanding Imaging CentersMedicare uses the Resource-Based Relative Value Scale (RBRVS) fee schedule to pay for services provided in freestanding imaging centers. Under this system, providers are required to bill for diagnostic radiology services using appropriate Current Procedural Terminology (CPT) codes. Each CPT code is assigned a set of relative value units (RVUs) that reflects the average


time, effort, and practice costs (including a geographic adjustment) involved in performing a given procedure. Medicare payment amounts are based on a procedure’s total RVUs multiplied by a dollar conversion factor. Currently, Medicare pays for 80 percent of the fee schedule amount and the patient (or the patient’s secondary insurer) is responsible for the remaining 20 percent. Within freestanding imaging centers, providers could bill a technical component, a professional component or a global fee that includes both the technical and professional component if the physician performs the procedure on-site.

Hospital Outpatient DepartmentsMedicare typically processes two claims for diagnostic radiology procedures performed in the hospital outpatient department: the hospital claim and the physician claim. The hospital submits a claim for the technical component and the physician submits a claim for the professional component. In August of 2000, Medicare changed the way hospital outpatient services are reimbursed. Medicare now reimburses hospitals under the hospital outpatient prospective payment system (PPS), commonly known as the ambulatory payment classifications (APC)* system. Payment under the new APC system will be determined by the services provided during an outpatient visit and identified by the appropriate CPT code.*Rulings around APCs are under review.

Hospital InpatientMedicare reimburses for hospital inpatient care, including diagnostic radiology procedures, using diagnosis-related groups (DRGs). DRGs are designed to group together inpatient admissions that, on average, are similar clinically and use comparable health care resources. Hospitals receive a fixed, pre-determined payment for each DRG, regardless of the actual services rendered. DRGs create strong incentives for hospitals to manage resources efficiently.

Workers’ CompensationWorkers’ compensation covers the diagnosis and treatment of conditions that result from a work-related injury. Many workers’ compensation programs pay all of the charges for care associated with an injury. Typically, reimbursement is based either on charges or on negotiated fees. As managed care organizations have become more involved in workers’ compensation issues, they have negotiated reimbursement rates with provider networks, and have started to review diagnostic services with more scrutiny.

TABLE 1

CODING SYSTEMS FREQUENTLY USED ON INSURANCE CLAIMS BY SETTING

FREESTANDING IMAGING CENTER

HOSPITAL OUTPATIENT DEPARTMENT

HOSPITAL INPATIENT

Patient Diagnosis

ICD-9 diagnosis codes ICD-9 diagnosis codes ICD-9 diagnosis codes

Imaging Procedure

CPT codes CPT codesRevenue codes

ICD-9 procedure codesRevenue codes

Contrast Agent

CPT and HCPCS codes Revenue codesCPT and HCPCS codes

Revenue

ICD-9 CodesThe International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) coding system contains both patient diagnosis and procedure codes. Providers in virtually all treatment settings use ICD-9 diagnosis codes to report patient conditions on insurance claims. Hospitals use ICD-9 procedure codes to identify medical, surgical, and diagnostic procedures performed in hospital inpatient settings.

Revenue CodesThe National Uniform Billing Committee, overseen by the American Hospital Association, developed a detailed set of accounting codes to standardize major revenue-producing centers


in an institutional setting. These codes identify categories of service like nuclear medicine, pharmacy, and laboratory. Hospitals use these codes to group the charges for itemized hospital services. Revenue codes generally appear on the hospital bill processed by most insurers.

CPT CodesThe Current Procedural Terminology (CPT-4) coding system is maintained by the American Medical Association and includes an exhaustive list of codes for surgical and medical procedures, as well as codes for consults, visits, and diagnostic tests. Physicians, freestanding imaging facilities, and hospital outpatient departments use CPT codes to bill for diagnostic and other procedures. The CPT system also includes two-digit modifiers to define services more specifically.

HCPCS CodesMedicare, and most Medicaid programs, require that physicians and hospital outpatient departments bill for drugs, supplies, and other items not identified by the CPT system using HCFA Common Procedure Coding System (HCPCS) codes. The HCPCS coding system consists of national codes created by HCFA to bill for nationally covered drugs and other items as well as local codes assigned by individual Medicare contractors. Under Medicare’s PPS system, some drugs, biologicals, contrast agents, or devices may not be included in the APC payment amount and instead may receive separate payment known as pass-through payment. Since APC groupings were determined by HCFA using data from 1996, many new and innovative products approved after this time would not have been accounted for under the new PPS. As a result, legislation was enacted in 1999 that required "transitional pass-through" or separate payment, for a specified period, for drugs, devices, and procedures that met specific criteria.HCFA has assigned HCPCS codes to these pass-throughs to be used only for Medicare services provided in the outpatient department. These "C codes" are transitional because special payment for these items will last no less than two and no more than three years. Currently, kits for the preparation of Technetium Tc 99m depreotide injection have been assigned a C-code for use in the outpatient department starting January 1, 2001. At the end of the effective period, HCFA will group kits for the preparation of Technetium Tc 99m depreotide injection into an established or newly established APC.

MAGNETIC RESONANCE COVERAGE AND PAYMENT POLICIESParamagnetic contrast agents, including the Berlex product gadopentetate dimeglumine injection, are used to enhance magnetic resonance imaging (MRI) procedures. Initially, the U.S. Food and Drug Administration (FDA) limited the use of these agents to MRI of the brain and spine. Subsequently in August 1993, gadopentetate dimeglumine injection was indicated for MRI contrast enhancement of all body areas except the heart.

Medicare Coverage PoliciesMagnetic Resonance Imaging ProceduresIn general, Medicare covers MRI procedures performed in hospital outpatient departments and freestanding imaging centers when they are considered reasonable and necessary for the diagnosis or treatment of an illness or injury.

Magnetic Resonance Angiography ProceduresEffective for services performed on or after July 1, 1999, Medicare provides coverage for MRA in four physical areas: 1) head and neck, 2) peripheral arteries of the lower extremities, 3) abdomen, and 4) chest. Medicare coverage for MRA in these four physical areas is determined according to the following policies: In the head and neck area, MRA generally is used to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral arteries, the vertebral or basilar arteries, or the venous sinuses. MRA also is performed on patients with conditions of the head and neck for which surgery is anticipated and may be found to be appropriate based on the MRA.


For 2001, the American Medical Association issued new codes for MRA of the head and MRA of the neck. Previous to 2001, MRA of the head/neck was represented by one code. These new coding scenarios may result in an updated coverage policy for MRAs.Studies have shown that use of an MRA is valuable in determining the presence and extent of peripheral vascular disease in the lower extremities. Evidence also indicates that MRA is superior to contrast angiography (CA) in finding occult vessels.Scientific data indicates that MRA of the abdomen is comparable to CA in determining the extent of abdominal aortic aneurysm (AAA), as well as evaluation of aortoilliac occlusion disease and renal artery pathology that may be necessary in the surgical planning for AAA repair.Medicare will cover MRA of the chest for diagnosing a suspected pulmonary embolism when it is contraindicated for the patient to receive intravascular iodinated contrast material. Use of MRA for evaluation of thoracic aortic dissection and aneurysm has shown a high level of diagnostic accuracy for pre-operative and post-operative evaluation of aortic dissection of aneurysm.In these four anatomical sites, Medicare will provide coverage for either CA or MRA, but not both, unless determined medically necessary in specific clinical circumstances. The physician must demonstrate the medical need for performing both tests.

Paramagnetic Contrast AgentsMedicare coverage for MRI procedures includes the use of contrast agents, such as gadopentetate dimeglumine injection and ferumoxides injectable solution, for their labeled indications. In general, Medicare covers gadopentetate dimeglumine injection for MRI enhancement of any body part (except the heart). Medicare also covers ferumoxides injectable solution for MRI contrast enhancement of liver lesions. Coverage, however, should not be confused with payment (see Medicare Payment Policies discussed below).

Medicare Payment PoliciesMRI ProceduresMedicare payment amounts for MRI studies vary by procedure and by site of service. In freestanding imaging centers, Medicare reimburses for MRI studies based on the RBRVS fee schedule, which varies by geographic region.As of January 1, 2001, under the APC system, a hospital will receive the same payment rate for all MRI and MRA procedures, regardless of body part scanned or whether the hospital outpatient department used contrast material. This is because HCFA classified these procedures under the same APC group. As of July 1, 2001, medicare will pay extra for contrast agents (see next section). The APC system only determines the hospital payment and does not affect the payment to physicians who perform the imaging MRA procedures. Physicians will continue to receive reimbursement under the physician fee schedule.

Paramagnetic Contrast AgentsMedicare will pay extra for paramagnetic contrast when used with MRI procedures on most body parts in freestanding facilities (effective January 1, 2001) and in hospitals (effective July 1, 2001). Prior to 2001, Medicare only paid extra for paramagnetic contrast when used in conjunction with MRI procedures of the brain and spine.

Private Insurance Coverage and Payment PoliciesLike Medicare, most private insurers cover MRI procedures when medically necessary, and pay extra for paramagnetic contrast agents. Whether or not you are reimbursed for paramagnetic contrast material will depend on the payer in question. Reimbursement from managed care plans will depend on the specific contract terms your facility negotiated with a given plan. Facing increasing pressures to contain costs, many private insurers are adopting bundled payment arrangements for services like contrast- enhanced diagnostic radiology studies.

Medicaid Coverage and Payment PoliciesMedicaid programs cover gadopentetate dimeglumine injection and ferumoxides injectable solution if the associated procedure is covered. However, many programs have limited benefits for diagnostic services. Check your state Medicaid program’s coverage policies if you need help researching specific guidelines or restrictions.


CODING AND CLAIMS SUBMISSION FOR MAGNETIC RESONANCE STUDIESFreestanding imaging centers and hospitals must use appropriate codes when submitting claims for magnetic resonance studies involving paramagnetic contrast material. Insurers generally require providers to report a supply code when an imaging study involves contrast, but the relevant CPT code does not specify its use. Hence, to bill for studies using gadopentetate dimeglumine injection or ferumoxides injectable solution, you must identify the appropriate CPT code(s) and determine whether those code(s) already account for the use of paramagnetic contrast.Recently, the American Medical Association issued a number of new MRI codes to delineate the various techniques performed with contrast material, without contrast material, and without contrast material followed by contrast material(s) and further sequences. When MRI codes were first developed, the use was primarily for central nervous system examinations (brain and spine), which were performed with contrast, without contrast material, or without contrast followed by contrast materials. However, for non-central nervous system scans, there were only single codes that made no mention of the use of contrast. As a remedy, the American Medical Association issued new MRI codes that further clarify the use of contrast during these procedures. These codes became effective January 1, 2001.

CODING SYSTEMS FREQUENTLY USED ON INSURANCE CLAIMS BY SETTINGExhibits 1 and 2 list available CPT codes for MRI and MRA procedures. Codes are grouped according to how they account for contrast use.

Freestanding Imaging CentersMost third-party payers ask freestanding imaging centers to bill for diagnostic radiology procedures using the HCFA 1500 claim form. For studies involving paramagnetic contrast, freestanding centers generally list one or more of the following codes:

ICD-9 diagnosis code(s), and

CPT procedure code(s).

Exhibit 7 is a sample HCFA 1500 claim form for freestanding imaging centers.

Hospital Outpatient DepartmentsMost third-party payers require two claims for MRI procedures performed in the hospital outpatient department; one claim for the hospital’s services and another claim for the physician’s professional services. Physician services generally are reported on the HCFA 1500 form using the appropriate CPT code(s) along with the 26 modifier to indicate professional services only. Hospital services generally are reported on the UB-92 form. For studies involving paramagnetic contrast, hospitals should list the following codes when billing for care in the hospital outpatient setting:

ICD-9 diagnosis code(s),

CPT procedure code(s), and

revenue codes.

Private insurers may also require the use of the above codes, but may additionally request an ICD-9 procedure code. Exhibit 3 lists ICD-9 procedure codes.Under Medicare’s new PPS, paramagnetic contrast agents may receive separate reimbursement in the hospital outpatient department. Hospitals should be certain to use appropriate CPT codes on all hospital outpatient claims to ensure accurate placement into an APC.When submitting claims for MRI procedures, hospitals should report the revenue code that describes the procedure, and if appropriate, the revenue code that indicates the use of


contrast. Table 2 presents the revenue code options. (See Exhibit 8 for a sample UB-92 claim form for hospital outpatient departments.)

TABLE 2

HOSPITAL REVENUE CODES FOR MAGNETIC RESONANCE PROCEDURES

CLAIM ITEM AHA REVENUE CODE HOSPITAL INPATIENT

AHA REVENUE CODE HOSPITAL OUTPATIENT DEPARTMENT

MRI Procedures

61X General Classification 32X Diagnostic Radiology

MRA Procedures

61X General Classification 32X Diagnostic Radiology

Hospital InpatientAs with hospital outpatient claims, most third-party payers require two claims for MRI procedures performed during an inpatient stay. Hospitals should bill for inpatient diagnostic radiology services using the same codes for hospital outpatient services. Hospital reimbursement for inpatient procedures, however, is included in the DRG assignment. Physician services generally are reported on the HCFA 1500 form using the appropriate CPT code(s) along with the 26 modifier to indicate professional services only. Medicare reimbursement for physician services are not included in the DRG payment, and thus are paid separately.

COVERAGE AND PAYMENT POLICIES FOR LOCMLow-osmolar contrast materials (LOCM), including iopromide injection, are used to enhance computed tomography (CT) scans and other selected diagnostic radiology procedures. Iopromide injection, specifically, is indicated for:

cerebral, peripheral, and coronary arteriography;

left ventriculography;

excretory urography;

aortography and visceral angiography;

peripheral venography;

contrast-enhanced CT scans of the head and body; and

intra-arterial digital subtraction angiography.

Medicare Coverage PoliciesMedicare has developed specific coverage guidelines for LOCM. Medicare’s policy states that LOCM is covered when administered 1) intrathecally, or 2) intravenously or intra-arterially when the patient demonstrates:

a history of previous reaction to contrast material except for a sensation of heat, flushing, or a single episode of nausea or vomiting;

a history or condition of asthma or allergy;

significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable angina pectoris, recent myocardial infarction and pulmonary hypertension;

generalized severe debilitation; or


sickle-cell disease.

Please note that iopromide injection is not indicated for intrathecal use. When administering LOCM intrathecally, please choose an agent that is indicated for intrathecal administration.

Medicare Payment PoliciesDiagnostic Radiology ProceduresMedicare calculates reimbursement for CT scans and other diagnostic radiology procedures based on where the procedure is performed. In freestanding imaging centers, Medicare reimburses for procedures based on the RBRVS fee schedule. Medicare pays for 80 percent of the fee schedule amount for a given procedure and the patient (or the patient’s secondary insurer) is responsible for the remaining 20 percent.Diagnostic radiology procedures performed in the hospital outpatient setting will be subject to Medicare’s APC-based payment system. The APC system will provide a fixed bundled payment for the radiology procedure performed. Effective July 1, 2001, Medicare will pay extra when hospital outpatient departments use contrast agents like LOCMs.

Low-Osmolar Contrast MaterialMedicare pays separately for LOCM only in freestanding imaging centers. In freestanding imaging centers, Medicare calculates its reimbursement rate by subtracting 8 percent from 95 percent of the average wholesale price or the estimated acquisition cost (EAC). Medicare reimburses 80 percent of the resulting reimbursement rate, and the patient is responsible for the remaining 20 percent. The choice between AWP or EAC is left up to the local Medicare contractor processing the claim. Because Medicare’s reimbursement projections are based on high-osmolar contrast material costs, contractors subtract 8 percent from 95 percent of AWP or EAC for LOCM to offset reimbursement accordingly. In hospital outpatient departments, Medicare will not pay separately for the LOCM.Medicare’s payment policies for iopromide injection and associated diagnostic radiology services are summarized in Table 3.Please note that these payment policies apply only if Medicare has decided to cover the iopromide injection and diagnostic radiology procedure. In other words, if a provider administers iopromide injection to a patient who does not meet Medicare’s coverage criteria, then Medicare will not pay separately for the agent.

TABLE 3

SUMMARY OF MEDICARE PAYMENT POLICIES FOR IOPROMIDE INJECTION BY SETTING

PAYMENT ITEMHOSPITAL OUTPATIENT DEPARTMENT

FREESTANDING IMAGING CENTERPHYSICIAN OFFICE

Diagnostic Radiology Procedure (technical component)

Ambulatory Payment Classification (APC)-based prospective payment system

RBRVS fee schedule

Diagnostic Radiology Procedure (professional component)

RBRVS fee schedule RBRVS fee schedule

Iopromide Injection Bundled 95 percent of AWP or EAC, less 8 percent

Private Insurance Coverage and Payment PoliciesMost private insurers cover iopromide injections, CT scans, and other diagnostic radiology procedures when determined to be medically necessary and appropriate. Some private insurers have medical criteria for coverage similar to those used by Medicare, while others have developed their own policies. Check your patient’s policy to determine specific policy limits that might apply to iopromide injection and associated diagnostic radiology procedures. Whether or


not you are reimbursed separately for LOCM will depend upon the payer in question, if it is a managed care plan, and the contract your facility has negotiated with that plan.

Medicaid Coverage and Payment PoliciesIn general, Medicaid’s coverage guidelines for LOCM mirror Medicare’s medical necessity guidelines. For more specific information, check the coverage policy of your state’s Medicaid program for specific guidelines for restrictions.Medicaid payment amounts vary significantly from state to state. Typically, Medicaid programs pay less than other insurers.

CODING AND CLAIMS SUBMISSION FOR LOCM STUDIESTo expedite reimbursement from insurers, freestanding imaging centers and hospitals must use the appropriate codes when submitting claims. Most payers require a claim with both a procedure code and a supply code when billing for diagnostic radiology services involving LOCM. There are three HCPCS codes specific to LOCM, each with a specified dosage range. In the event an insurer does not accept one of the codes, providers can bill for LOCM using CPT code 99070.Exhibit 4 lists available CPT codes for diagnostic radiology services.Table 4 presents coding options for billing iopromide injection.

TABLE 4

SUPPLY CODES FOR IOPROMIDE INJECTION

THIRD-PARTY PAYER

CODE* DESCRIPTION

Medicare, some Medicaid programs and some private payers

A4644 Supply of LOCM (100-199 mg of iodine)



Some Medicaid programs and private payers

99070 Physician supplies and materials (except spectacles), over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)

Freestanding Imaging CentersMost insurers ask freestanding imaging centers to bill for diagnostic radiology procedures using the HCFA 1500 form. For studies involving LOCM, freestanding centers generally list one or more of the appropriate codes:


CPT code(s), and

HCPCS or CPT code for LOCM.

Exhibit 9 is a sample HCFA 1500 form for a freestanding imaging center.

Hospital Outpatient DepartmentsMany facilities will generate two bills for hospital-based diagnostic radiology services — one for the hospital’s services and another for the physician’s services. Most insurers ask that hospitals submit claims for the technical portion of the study using the UB-92 claim form. For studies performed in the hospital outpatient department, involving LOCM, hospitals should list the following codes:



CPT code(s), and

revenue codes.

Private insurers may also require the use of the above codes, but may additionally request an ICD-9 procedure code. Exhibit 5 lists ICD-9 procedure codes.Under Medicare’s new PPS, contrast material like LOCMs will receive separate reimbursement in the hospital outpatient department, effective July 1, 2001.Revenue codes applicable to diagnostic radiology procedures involving LOCM are presented in Table 5.Physician services generally are reported on the HCFA 1500 form using CPT codes along with the 26 modifier to indicate the professional portion of the study only.

TABLE 5

REVENUE CODES FOR IOPROMIDE INJECTION AND DIAGNOSTIC RADIOLOGY PROCEDURES

Claim Item AHA Revenue Code Hospital Inpatient

AHA Revenue Code Hospital Outpatient Department

Iopromide Injection 250 Pharmacy 250 Pharmacy

Selected Diagnostic Radiology Procedures

32X Diagnostic Radiology

32X Diagnostic Radiology34X Nuclear Medicine (CPT Code 78635)

CT Procedures 35X CT Scan 32X Diagnostic Radiology

Hospital InpatientAs with hospital outpatient claims, most third-party payers require two claims for diagnostic radiology procedures performed during an inpatient stay. Hospitals should bill for inpatient services using appropriate ICD-9 diagnosis and procedure codes, as well as revenue codes. Hospital reimbursement for inpatient procedures, however, is included in the DRG payment amount based on the patient’s DRG assignment. Physician services generally are reported on the HCFA 1500 form using the appropriate CPT code(s) along with the 26 modifier to indicate professional services only. Medicare reimbursement for physician services are not included in the DRG payment, and thus are paid separately.

Using information in this document does not ensure that you will be successful in obtaining insurance payment. Third-party payment for medical products and services is affected by numerous factors, many of which are beyond the scope of matters discussed within this document.

COVERAGE AND PAYMENT POLICIES FOR NUCLEAR MEDICINEScintigraphic imaging agents, including kits for the preparation of Technetium Tc 99m depreotide injection and kits for the preparation of Technetium Tc 99m apcitide injection, are diagnostic tools used to identify disease processes rather than just anatomical structures. Kit for the preparation of Technetium Tc 99m depreotide injection, specifically, is indicated for the scintigraphic imaging of somatostatin receptor-bearing masses in the lungs, in patients presenting with pulmonary lesions on CT and/or x-ray who have known malignancy or who are highly suspect for malignancy. Kits for the preparation of Technetium Tc 99m apcitide injection is indicated for scintigraphic imaging of acute venous thrombosis in the lower extremities of patients who have signs and symptoms.

Medicare Coverage and Payment Policies


In general, Medicare covers scintigraphic imaging procedures performed in hospital outpatient/inpatient departments and freestanding imaging centers when they are considered reasonable and necessary for the diagnosis or treatment of illness or injury.Medicare payment amounts for scintigraphic imaging studies vary by procedure and by site of service. In freestanding imaging centers, Medicare reimburses for scintigraphic imaging studies based on the RBRVS fee schedule, which varies by geographic region. Scintigraphic studies performed in the hospital outpatient setting will be paid according to the APC payment level assigned to the CPT code.

Private Insurance Coverage and Payment PoliciesMost private insurers cover kits for the preparation of Technetium Tc 99m depreotide injection and kits for the preparation of Technetium Tc 99m apcitide injection for scintigraphic procedures when determined to be medically necessary and appropriate. Some private insurers may have medical criteria for coverage similar to Medicare, while others have developed their own policies. Check your patient’s policy to determine specific policy limits that might apply to kits for the preparation of Technetium Tc 99m depreotide injection or kits for the preparation of Technetium Tc 99m apcitide injection and associated diagnostic scintigraphic imaging procedures. Whether or not you are reimbursed separately for kits for the preparation of Technetium Tc 99m depreotide injection or kits for the preparation of Technetium Tc 99m apcitide injection will depend upon the payer in question, if it is a managed care plan, and the contract your facility has negotiated with that plan.

Medicaid Coverage and Payment PoliciesIn general, Medicaid’s coverage guidelines for scintigraphic imaging and radionuclide imaging material mirror Medicare’s medical necessity guidelines. For more specific information, check the coverage policy of your state’s Medicaid program for specific guidelines for restrictions.Medicaid payment amounts vary significantly from state to state. Typically, Medicaid programs pay less than other insurers.



To expedite reimbursement from insurers, freestanding imaging centers and hospitals must use the appropriate codes when submitting claims. Most payers require a claim with both a procedure code and a supply code when billing for scintigraphic imaging services involving kits for the preparation of Technetium Tc 99m depreotide injection or kits for the preparation of Technetium Tc 99m apcitide injection.Exhibit 6 lists available CPT codes for nuclear medicine scintigraphic imaging studies.Table 6 presents coding options for billing kits for the preparation of Technetium Tc 99m depreotide injection in various settings. Table 6A presents coding options for billing kits for the preparation of Technetium Tc 99m apcitide injection in various settings.

SUPPLY CODES FOR KITS FOR THE PREPARATION OF TECHNETIUM Tc 99m DEPREOTIDE INJECTION

Third-Party Payer by Setting Code Description

Hospital Outpatient Department

Medicare C1095 Tc 99m depreotide, kit for the preparation of Technetium Tc 99m depreotide injection

Freestanding Facility

Medicare, some Medicaid programs, and some private payers

A4641 or 78990

Supply of radiopharmaceutical diagnostic imaging agent (Submit copy of invoice with Medicare or Medicaid claims)

TABLE 6A

SUPPLY CODES FOR KITS FOR PREPARATION OF TECHNETIUM Tc 99m APCITIDE INJECTION

Third-Party Payer by Setting Code Description

Hospital Outpatient Department and Freestanding Facilities

Medicare, some Medicaid programs, and some private payers

A9504 or 78990

Tc 99m apcitide, kit for the preparation of Technetium Tc 99m apcitide injection

Freestanding Imaging CentersMost insurers ask freestanding imaging centers to bill for scintigraphic imaging procedures using the HCFA 1500 form. For studies involving kits for the preparation of Technetium Tc 99m depreotide injection or kits for the preparation of Technetium Tc 99m apcitide injection, freestanding centers generally list one or more of the appropriate codes:


CPT procedure code(s), and

HCPCS or CPT code for kits for the preparation of Technetium Tc 99m depreotide injection or kits for the preparation of Technetium Tc 99m apcitide injection.

Exhibits 12 and 13 are sample HCFA 1500 forms for a freestanding imaging center.

Hospital Outpatient DepartmentsMany facilities will generate two bills for hospital-based scintigraphic imaging services – one for the hospital’s services and another for the physician’s services. Most insurers ask that hospitals submit claims for the technical portion of the study using the UB-92 claim form. For studies performed in the hospital outpatient department, involving kits for the preparation of Technetium Tc 99m depreotide


CODING AND CLAIMS SUBMISSION FOR NUCLEAR MEDICINEHospital Outpatient DepartmentsMany facilities will generate two bills for hospital-based scintigraphic imaging services – one for the hospital’s services and another for the physician’s services. Most insurers ask that hospitals submit claims for the technical portion of the study using the UB-92 claim form. For studies performed in the hospital outpatient department, involving kits for the preparation of Technetium Tc 99m depreotide injection or kits for the preparation of Technetium Tc 99m apcitide injection, hospitals should list the following codes:


CPT procedure code(s),

HCPCS code C1095 (Medicare only), A4641 or 78990 for kits for the preparation of Technetium Tc 99m depreotide injection,

HCPCS code A9504 or 78990 for kits for the preparation of Technetium Tc 99m apcitide injection, and

revenue codes.

As mentioned above, under APCs, certain drugs receive separate or pass-through payment. Because they are radiopharmaceuticals, HCFA granted kits for the preparation of Technetium Tc 99m depreotide injection and kits for the preparation of Technetium Tc 99m apcitide injection pass-through status. In order to identify products like kits for the preparation of Technetium Tc 99m depreotide injection and kits for the preparation of Technetium Tc 99m apcitide injection during claims submissions, Medicare has designated product-specific HCPCS codes or C-codes that are required for payment. These C-codes can be used to bill for specific drug products only in the hospital outpatient setting. In the freestanding facility, providers should use A4641 to account for kits for the preparation of Technetium Tc 99m depreotide injection. However, A9504 can be billed by freestanding sites.

Private insurers may also require the use of the above codes, but may additionally request an ICD-9 procedure code. However, hospitals should not use HCPCS code C1095 when submitting claims to private insurers. Private insurers may require the use of a miscellaneous supply code for kits for the preparation of Technetium Tc 99m depreotide injection, such as A4641. Check your patient’s policy to determine specific coding requirements that might apply to kits for the preparation of Technetium Tc 99m depreotide injection and associated diagnostic scintigraphic imaging procedures. However, facilities should be able to use A9504 when submitting claims for kits for the preparation of Technetium Tc 99m apcitide injection.

Revenue codes applicable to nuclear medicine procedures involving kits for the preparation of Technetium Tc 99m depreotide injection and kits for the preparation of Technetium Tc 99m apcitide injection are presented in Table 7.

Physician services generally are reported on the HCFA 1500 form using CPT codes along with the 26 modifier to indicate the professional portion of the study only.

TABLE 7

REVENUE CODES FOR KITS FOR THE PREPARATION OF TECHNETIUM Tc 99m DEPREOTIDE INJECTION AND NUCLEAR MEDICINE

PROCEDURES

Claim Item AHA Revenue Code Hospital Inpatient


Kit for the preparation of Technetium Tc 99m depreotide injection

250 Pharmacy 636 Radionuclides

Kit for the preparation of Technetium Tc 99m apcitide injection


Selected Nuclear Medicine Procedures

34X Nuclear Medicine


Hospital InpatientAs with hospital outpatient claims, most third-party payers require two claims for scintigraphic imaging procedures performed during an inpatient stay. Hospitals should bill for inpatient services using appropriate ICD-9 diagnosis and procedure codes, as well as revenue codes. Hospital reimbursement for inpatient procedures, however, is included in the DRG payment amount based on the patient’s DRG assignment. Physician services generally are reported on the HCFA 1500 form using the appropriate CPT code(s) along with the 26 modifier to indicate professional services only. Medicare reimbursement for physician services are not included in the DRG payment, and thus are paid separately.

EXHIBIT 1CPT Codes for MRI Procedures

Codes That Distinguish Procedures With and Without ContrastCod

eDescription

70540 MRI, orbit, face, and neck; without contrast material

70542 MRI, orbit, face, and neck; with contrast material

70543 MRI, orbit, face, and neck; without contrast material, followed by contrast material and further sequences

70551 MRI, brain (including brain stem); without contrast material

70552 MRI, brain (including brain stem); with contrast material

70553 MRI, brain (including brain stem); without contrast material, followed by contrast material and further sequences

71550 MRI, chest (e.g. for evaluation of hilar and mediastinal lymphadenopathy); without contrast material

71551 MRI, chest (e.g. for evaluation of hilar and mediastinal lymphadenopathy); with contrast material

Code Description

73222 MRI, any joint of upper extremity; with contrast material

73223 MRI, any joint of upper extremity; without contrast material, followed by contrast material and further sequences

73718 MRI, lower extremity, other than joint; without contrast material

73719 MRI, lower extremity, other than joint; with contrast material

73720 MRI, lower extremity, other than joint; without contrast material, followed by contrast material and further sequences

73721 MRI, any joint of lower extremity; without contrast material

73722 MRI, any joint of lower extremity; with contrast material

73723 MRI, any joint of lower extremity; without contrast material, followed by contrast material and further sequences

74181 MRI, abdomen; without contrast material

74182 MRI, abdomen; with contrast material

74183 MRI, abdomen; without contrast material, followed by contrast material and further sequences

75552 Cardiac MRI for morphology, without contrast

75553 Cardiac MRI for morphology, with contrast

TABLE 7

REVENUE CODES FOR KITS FOR THE PREPARATION OF TECHNETIUM Tc 99m DEPREOTIDE INJECTION AND

NUCLEAR MEDICINE PROCEDURES

Claim ItemAHA Revenue Code Hospital Inpatient


Kit for the preparation of Technetium Tc 99m depreotide injection


Kit for the preparation of Technetium Tc 99m apcitide injection


Selected Nuclear Medicine Procedures



Hospital InpatientAs with hospital outpatient claims, most third-party payers require two claims for scintigraphic imaging procedures performed during an inpatient stay. Hospitals should bill for inpatient services using appropriate ICD-9 diagnosis and procedure codes, as well as revenue codes. Hospital reimbursement for inpatient procedures, however, is included in the DRG payment amount based on the patient’s DRG assignment. Physician services generally are reported on the HCFA 1500 form using the appropriate CPT code(s) along with the 26 modifier to indicate professional services only. Medicare reimbursement for physician services are not included in the DRG payment, and thus are paid separately.


EXHIBIT 2CPT-4 Codes for MRA Procedures

Code Description

70544 MRA, head; without contrast material(s)

70545 MRA, head; with contrast material(s)

70546 MRA, head; without contrast material(s), followed by contrast material(s) and further sequences

70547 MRA, neck; without contrast material(s)

70548 MRA, neck; with contrast material(s)

70549 MRA, neck; without contrast material(s), followed by contrast material(s) and further sequences

73225 MRA, upper extremity, without contrast

73725 MRA, lower extremity, with or without contrast

74185 MRA, abdomen, with or without contrast material

EXHIBIT 4CPT-4 Codes for Diagnostic Radiology Procedures Using Low-Osmolar Contrast Material

Computerized Tomography ProceduresCod

eDescription

70450 Computerized axial tomography, head or brain; without contrast

70460 Computerized axial tomography, head or brain; with contrast

70470 Computerized axial tomography, head or brain; without contrast followed by contrast and further sections

76375 Computerized tomography, coronal, sagittal, multiplanar, oblique and/or three-dimensional reconstruction

Selected Diagnostic Radiology ProceduresCod

eDescription

74400 Urography (pyelography), intravenous, with or without KUB, with or without tomography

75600 Aortography, thoracic, without serialography, radiological supervision and interpretation

75605 Aortography, by serialography, radiological supervision and interpretation

75665 Angiography, carotid, cerebral, unilateral,

EXHIBIT 5ICD-9-CM Codes for Diagnostic Radiology Procedures

Using Low-Osmolar Contrast Material*Cod

eDescription

87.03 Computerized axial tomography, head

87.41 Computerized axial tomography, thorax

87.71 Computerized axial tomography, kidney

87.73 Urography, excretory

88.01 Computerized axial tomography, abdomen

88.38 Computerized axial tomography, other

88.4 Angiography/arteriography

88.53 Ventriculography, cardiac, left ventricle (outflow tract)

88.57 Arteriography, coronary, other and unspecified

88.98 Bone mineral density studies (quantitative computer tomography studies)

*This table should not be used as the definitive coding source. Please consult

72158

MRI, spinal canal and contents, lumbar, without contrast material, followed by contrast material and further sequences

72195

MRI, pelvis; without contrast material

72196

MRI, pelvis; with contrast material

72197

MRI, pelvis; without contrast material, followed by contrast material and further sequences

73218

MRI, upper extremity, other than joint; without contrast material

73219

MRI, upper extremity, other than joint; with contrast material

73220

MRI, upper extremity, other than joint; without contrast material, followed by contrast material and further sequences

73221

MRI, any joint of upper extremity; without contrast material

Codes That Do Not Specify ContrastCode Description

70336 MRI, temporomandibular joint

75554 Cardiac MRI for function with or without morphology; limited study

75555 Cardiac MRI for function with or without morphology; limited study

The codes listed above represent possible coding options. It is always the provider’s responsibility to determine and submit appropriate codes for the services rendered. Berlex does not recommend the use of any particular procedure code for any particular patient. The patient’s medical record must support all procedures on a claim form. CPT and ICD-9 codes should support each other and justify medical necessity.




















































CPT Codes for MRI ProceduresCodes That Distinguish Procedures With and Without ContrastCodeDescription70540MRI, orbit, face, and neck; without contrast material70542MRI, orbit, face, and neck; with contrast material70543MRI, orbit, face, and neck; without contrast material, followed by contrast material and further sequences70551MRI, brain (including brain stem); without contrast material70552MRI, brain (including brain stem); with

contrast material 70553MRI, brain (including brain stem); without contrast material, followed by contrast material and further sequences71550MRI, chest (e.g. for evaluation of hilar and

mediastinal lymphadenopathy); without contrast material71551MRI, chest (e.g. for evaluation of


hilar and mediastinal lymphadenopathy); with contrast material71552MRI, chest (e.g. for evaluation of hilar and mediastinal lymphadenopathy); without contrast material, followed by contrast material and further sequences 72146MRI, spinal canal and contents, thoracic; without contrast material72147MRI, spinal canal and contents, thoracic; with contrast material72148MRI,

spinal canal and contents, lumbar; without contrast material72149MRI, spinal canal and contents, lumbar, with contrast material72157MRI, spinal canal and contents, thoracic; without

contrast material, followed by contrast material and further sequences72195MRI, pelvis; without contrast material72196MRI, pelvis; with contrast material72197MRI, pelvis; without contrast

material, followed by contrast material and further sequences73218MRI, upper extremity, other than joint; without contrast material73219MRI, upper extremity, other than joint; with contrast

material73220MRI, upper extremity, other than joint; without contrast material, followed by contrast material and further sequences73221MRI, any joint of upper extremity; without contrast

material


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