MEDICAL BILLING TRAINING MANUAL�

MEDICAL BILLING TRAINING MANUAL�

Medical billing & Coding is the process of submitting and following up on claims to insurance companies in order to receive payment………………..

Medical billing translates a health care service into a billing claim. The responsibility of the medical biller in a health care facility is to insure that Billing for Medical Provider is completed and transmitted following correct billing rules and regulations as per insurance guidelines.

follow that claim to ensure the practice receives reimbursement for the work the providers perform. A knowledgeable biller can optimize revenue performance for the practice.

Although a medical biller’s duties vary with the size of the work facility, the biller typically assembles all data concerning the bill. This can include charge entry, claims transmission, payment posting, insurance follow-up and patient follow-up. Medical billers regularly communicate with physicians and other health care professionals to clarify diagnoses or to obtain additional information. Therefore, the medical biller must understand how to read the medical record and, like the medical coder, be familiar

with CPT®, HCPCS Level II and ICD-9-CM codes.�

Complete Medical Billing Cycle:

TYPE OF INSURANCE COMPANY�

1. Federal Insurance
2. Commercial
3. Workers Comp

INTRODUCTION OF GOVT. INSURANCES

A-Federal Insurance

1. Medicare
2. Medicaid
3. Tricare
4. RR Medicare (RR-Rail Road)

Medicare Eligible�

Medicare insurances guidelines are same for ALL US states and their CREDENTIALING is done through PECOS portal.

Administrated directly by the federal government.

1. People 65 Years above
2. People Under 65 with certain Disabilities
3. People of any aged with End-Stage Renal Disease (ESRD)Note: Patient must be Tax payer in order to get Medicare The person will not get Medicare benefits even satisfy the above three conditions if not tax payer.

The Different parts of Medicare

1. Part A
2. Part B
3. Part C
4. Part D

Part A (Hospital Insurance)

It is also known as INSTITUTIONAL / FACILITY billing.

Only Covered with Hospital Services. ( Ex. Bed Charges & Equipment charges) Its Cover Inpatient care in Hospital.

Its cover Skilled Nursing facility, hospice (Near to death people / people having worse condition) and home health care. Claims billing to UB92 & UB04 forms.

Part B (Medical Insurance)�

It is also known as DOCTORS / PROFESSIONAL BILLING.

Its Covered with Doctors’ Services, hospital outpatient care and home health care or if the doctor is giving the consultation online. If provider gives services to patient in private clinic, Home, Hospital, Home health care etc provider services will be covered in PART B.

Its cover some Preventive services to help maintain your health and to keep certain illness from getting worse

Claims Billing to HCFA & CMS1500 forms.

Part C (PartA+PartB+PartD)/MCO/Advantage plans

Medicare Advantage plans (like an HMO or PPO) are health plans run by Medicare-approved private insurance companies. Medicare Advantage plans (also called Part C) include Part A, Part  B and usually other coverage like Medicare prescription drug coverage (Part D), sometimes for  an extra cost. It is a Medicare/Medicaid plan but covered by some commercial insurances. In this plan we can check the eligbility and benefits from Medicare/Medicaid and that commercial insurance however claim is billed and covered by commercial insurance. To provide High quality service at low Cost.(Managed Care plans)

Part D ( Medicare prescription Drug Coverage)

Only Covered with Drug Program ( supply for Medicine) Ex: Sugar Patient.

Medicaid:

It is also known as the State Insurance and its guidelines vary from state to state.

It’s covered with below Poverty people (or) Low income people. It’s monthly month basic.

Administrated by Each State Law. The patient has no out of state benefits in Medicaid plan e.g member have CA Medicaid insurance will not covered the benefits FL state but only cover CA providers. The patient must go to the providers within the state.

Tricare:

It’s Coved with Army people.

Tricare Two Types:

1. CHAMPVA (Civilian Health and Medical program for Veteran affairs or for retired people).
2. CHAMPUS (Civilian Health and Medical program for Uniformed services or for on duty people).

RR Medicare:�

It’s covered with Railway Department, Transport Department & Highway’s Department.

B-Worker’s Compensation:

It’s covered with Work related injury and work relevant accident.

Auto Accident:

It’s covered with Vehicle Accident.

Two types of Auto Accident:

1. No fault Auto Accident
2. Non-No fault Auto Accident

Managed Care Plans:

To provide High quality service at low Cast.

• HMO (Health Maintenance Organization)

Patient must goes to in-network Provider. PCP Must. (Low premiums, low deductible, co pay& coins). PCP means Primary care Physician. In this plan no Out of network benefits.

Patient goes to PCP first and PCP Issue Referral for specialist visit according to Diagnose. For PCP Referral PCP should contact the insurance and generate the referral.�

• EPO (Exclusive Provider Organization)

An Exclusive Provider Organization (EPO) is a health insurance plan that limits members to using a In Network of providers and facilities. However, members usually don’t need to use a primary care doctor or get referrals to see in-network specialists. EPOs may also offer access to a large, national network of providers. So, they have only In network provider benefits and no PCP referral is required.�

• PPO (Preferred Provider Organization)

Patient may go to any Healthcare Provider in listed Panel doctors, anywhere; Include out of Network If benefits are available.

• POS (Point of Services)

It’s companied with HMO+PPO. Like HMO this plan has PCP and In Network benefits and like PPO it has Out of Network benefits.

Patient goes to any network provider (In or Out). PCP selection is not required.

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

COBRA:

The term COBRA is an acronym for the Consolidated Omnibus Budget Reconciliation Act of 1986—federal legislation that governs the operation of group-sponsored health plans of businesses with twenty or more employees. The COBRA Plan will offer continuing healthcare coverage to you and your dependents if you leave your job.

You will have to pay the entire COBRA premium on your own, however.

It’s possible to extend COBRA’s Coverage for up to 18 months and a surviving dependent can

receive further extensions

Health Accounts:

Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs), and Flexible Spending Accounts (FSAs) are all tax-advantaged accounts that help people save on healthcare. They are also known as account-based health plans (ABHPs). Here are some differences between them:

HSAs:

These are personal bank accounts that employees own and can contribute to pre-tax dollars from their paycheck. Employees can also choose to have their employer contribute to their HSA. HSAs can be used to pay for qualified medical expenses and out-of-pocket healthcare costs. Employees can purchase health coverage through an employer, an exchange or marketplace, or directly from a health insurance company.

HRAs:

These are employer-owned accounts that employers contribute to tax-free funds to help employees pay for health expenses. HRAs can be used to pay for qualified medical expenses and expenses not covered by an employee’s health insurance plan, such as deductibles and coinsurance. Employees can’t contribute to HRAs, and the funds don’t roll over if they leave the company. HRAs are only available to employees who receive health care coverage from their employer.�

FSAs:

These are spending accounts that employees and their employers can contribute pre-tax dollars to. FSAs can be used to pay for out-of-pocket healthcare costs and other eligible expenses. FSAs are only available through an employer.

PAR Provider: (Participating Provider)

A participating provider is a healthcare professional or facility that has an agreement with an insurance company or managed care organization to provide services to their members at a discount. Participating providers are also known as “in-network” providers.�

Participating providers agree to accept the insurer’s approved fee schedule, which can result in lower out-of-pocket costs for insured individuals. The arrangement also benefits the provider, who may receive more patient referrals and simplified billing.�

Health plans may offer incentives to encourage members to see participating providers. However, the discount may not be as great as preferred providers, and members may still have to pay more. For example, when seeing a participating Medicare provider, members are responsible for paying a 20% coinsurance for Medicare-covered services.

Capitation and fee-for-service (FFS)

Capitation and fee-for-service (FFS) are both payment models used in the US healthcare system to compensateIn Network providers for their services. Fee-for-service (FFS) means that providers bill and are paid for each medical service delivered – physician visit, test or intervention, hospital day. Capitation means that providers are paid a monthly amount per beneficiary for all services or just some (e.g., primary care).

Capitation:

Providers are paid a fixed monthly amount per patient for all or some services. The amount is typically based on historical reimbursement. Capitation is considered a quality-based model, and providers may contract with an Independent Physician Association (IPA) to receive their payments.�

FFS:

Providers are paid for each service they deliver, such as a physician visit, test, intervention, or hospital day. FFS is considered a traditional payment model.�

Some say that FFS can be costly and cumbersome for providers and patients, but it may be useful in areas where capitation alone isn’t feasible. Others say that primary care physicians may provide more services under FFS than under capitation

1. Fixed Capitation
2. Rolling Capitation

• Fixed Capitation:

Fixed capitation, also known as capitation, is a payment model in medical billing where healthcare providers receive a predetermined amount of money for each patient enrolled in a health plan over a specific period of time. The payment is made in advance and is intended to cover the predicted cost of all or some of the patient’s healthcare services. The capitation rate is fixed and is based on a number of factors, including the provider’s practice location, historical trends, and the number of patients in the agreement. The payment is usually made monthly, but can also be made annually.

• Rolling Capitation:

Provider will be get the fixed amount for every patient.

Non-PAR Provider (Non-Participating Provider)

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

Medical Terminologies

Premium:

A medical premium is the monthly fee you pay to have health insurance. It’s similar to a car payment, in that you must make regular payments to keep your plan active. You can pay the entire premium yourself, or your employer may pay all or part of it. You may also qualify for help from the federal government to pay for your premium.�

In addition to your premium, you usually have to pay other costs for your health care, including deductibles, copayments, and coinsurance. These costs vary depending on your plan and your cost-sharing.

Patient Insurance�

Grace Period:

A grace period in medical billing is a short time after a monthly health insurance payment is due when the policyholder can pay any outstanding premiums and avoid losing coverage or penalties. The length of the grace period can vary depending on the policy and the insurer, but is usually between 15 and 30 days. The policy’s terms and conditions will specify the grace period.�

During the grace period, the insurance company may not cover any medical expenses incurred by the policyholder. Coverage will only be reinstated once the premium is paid, and the policyholder will be responsible for any medical expenses that occurred during the grace period.�

The grace period may also differ for policyholders who receive an advance premium tax credit (APTC) and those who do not. For example, Medica offers a three-month grace period for policyholders who receive an APTC, and a 31-day grace period for those who do not.

Patient responsibility:

Patient responsibility is commonly described as the total amount a patient owes out of pocket or the amount due on a bill that the patient is responsible for. If the patient is insured, it may include copayments or coinsurance. For self-paying patients or those who haven’t met their deductible, patient responsibility for payment could equal 100 percent of total charges. Mainly there are three types of patient responsibility.

Deductible: (PR1)

The amount a patient must pay out of pocket before their health plan begins to pay for covered health care. Patients are responsible for all medical costs until they reach their deductible. Medicare & Commercial insurance starts in January of each year.

Tricare insurance starts in October of each year.

Medicare Annual Deductibles�

2017 PART-B annum Deductible Amount -$183.00
2018 PART-B annum Deductible Amount -$183.00
2019 PART-B annum Deductible Amount -$185.00
2020 PART-B annum Deductible Amount -$198.00
2021 PART-B annum Deductible Amount -$203.00
2022 PART-B annum Deductible Amount -$233.00
2023 PART-B annum Deductible Amount -$226.00
2024 PART-B annum Deductible Amount -$240.00

Coinsurance: (PR2)

A percentage of the total medical cost that you pay after you’ve met your plan’s annual deductible. Coinsurance is billed after your insurance company approves the charges for a service. For example, if your plan’s allowed amount for a treatment is $100 and your coinsurance is 30%, you would pay $30.�

Copay: (PR3)

A fixed amount that the patient pay for a specific service to providers after you’ve met your plan’s annual deductible, such as a doctor’s visit, prescription, or emergency room visit. Copays are usually paid each time you use a service, and they can vary based on the type of care. For example, copays for routine health issues are usually less than $100, but copays for specialist or emergency visits may be higher. For example, if your plan’s allowed amount for a treatment is $100 and your copay is $20, you would pay $20 and insurance pay $80.

Allowed Amount = Insurance Paid + Patient Responsibility

Out-of-pocket maximum:

The most a patient could spend on medical bills in a year. This is also known as the annual out-of-pocket limit.

Authorization:

Authorization is the process of getting approval for a medical service or procedure before it is given. This is done to ensure that the service or procedure is covered by insurance. Authorization is usually required if you need a complex treatment or prescription.

Two types of Authorization

1. Prior Authorization
2. Retro Authorization
   

Prior Authorization:

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

Retro Authorization:

After rendered the service provider get approval from the insurance company. It’s exceptional only. Mostly insurances do not issue retro Auth.

PCP Referral:

A  PCP referral is also an authorization provided by the Primary Care Physician referring a patient to a specialist. Submitting a referral along with a claim is necessary to get reimbursement.

ABN: (Advance Beneficiary Notice)

A notice that hospital/Provider gives the patient before they receive services when Medicare/Medicaid is not expected to pay for some or all of the service.

AOB: (Assignment of Benefits)

Patient assigned benefits to the provider behalf of the treatment.

COB: (Coordination of Benefits)

In medical billing, COB stands for Coordination of Benefits, which is a process that insurance companies use to determine how to cover a patient’s medical expenses when they have more than one health insurance plan. COB helps ensure that claims are paid correctly, and that patients don’t receive duplicate or overpayment.�

COB works by identifying which plan is the primary payer and which is secondary, and then establishing an order for each company to pay. The primary payer is responsible for the largest share of the cost, while the secondary payer covers the remaining balance. COB can also help families with two wage earners receive up to 100% coverage for medical services.

When we confirm the COB we need to two piece of information 1st last COB update date 2nd on that date what decision was made by patient means who is the primary and secondary insurance.�

SSN: (Social Security Number)

This Number all US Citizen Must. This Number Given by Social Security Administrator. SSN 3- 2-4 format. First 3digit-Area Code 2digit-Group no. 4digit-Serial no.

Allowed Amount:

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

Refund or Take Back

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

Offset or Recoupment amount

If the provider not refund the amount to the insurance company payment will be adjusted on the next  Claim.

Modifier:

In medical billing, a modifier is a two-digit code that’s added to a medical billing code to provide more information about a service or procedure. Modifiers can be numeric, alphabetic, or a combination of both. A modifier is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. They can indicate things like:�

Location: Which side of the body a procedure was performed on�

Provider: Who performed the service�

Circumstances: Unusual circumstances that may affect the billing�

Services: Whether not all services in a bundle were performed�

Modifiers are important for ensuring accurate and appropriate reimbursement for medical services. They allow medical records technicians and billing specialists to provide a more detailed description of services without changing the definition of those services. For example, a modifier can be used to indicate that a service was performed on the upper left eyelid (E1) or the lower right eyelid (E4).

Modifiers may be used under the following circumstances:-

• A service or procedure has both a professional and technical component.
• A service or procedure was performed by more than one physician and/or in more than one location.
• A service or procedure has been increased or reduced.
• Only part of a service was performed.
• A bilateral procedure was performed.
• A service or procedure was provided more than once.
• Unusual events occurred.
• 59: Used to indicate a distinct procedural service�
• 25: Significant, separately identifiable evaluation and management service by the same physician or other healthcare professional on the same day of the procedure or other service
• 26: Modifier 26 is used to bill the component of a service when it has both professional and�
• GT: Used for telehealth services that take place via interactive audio and video telecommunications systems.�
• 95: Used for synchronous telemedicine services that take place via real-time interactive audio and video communications systems.�
• E1: Used to indicate the upper left eyelid�
• TC: Used to indicate a technical component�
• XS: Used to indicate a separate structure, such as a service that was performed on a different organ or structure�
• 52: Used to indicate reduced services, such as when a procedure was completed but not fully successfully�
• 57: Used to indicate an E/M service that led to the initial decision to perform surgery�
• LT: Used to indicate the left side of the body�
• RT: Used to indicate the right side of the body�
• GC: Used to indicate a service performed by students or residents under the guidance of a teaching physician�
• 27: Used by hospital and outpatient facilities when multiple outpatient hospital E/M encounters occur for the same member on the same day of service

• Information Modifier:

Also known as statistical modifiers, they provide procedural details. For example, they can indicate which side of the body a procedure was performed on, or if a service bundle was incomplete. It does not vary the payment just intimate the insurance company which part of the organ service was rendered eg.LT, RT, AI, KX, KO

• Reimbursement Modifier:

Also known as functional modifiers, they determine the appropriate fee for a service and are part of the procedure code. Modifier 51 is an example of a pricing modifier. Every the payment who render the service patient (EX) PC, TC, 24,25,26,59,78,79

CMS:

Centers of Medicare and Medicaid Service

POS: (Place of Service)

It’s Indicate where the service was rendered. (EX) Hospital ,Clinic, Home etc. Mostly Used are mentioned below.

11- Office 12-Home 13-Assisted Living Facility 20-Urgent Care

21-Hospital In Patient 22-Hospital Out Patient 23-Emergencey Room 31-Skilled Nursing Facility   32-Nursing Facility 34-Hopsice

81-Independent Laboratory

02- Telehealth provided other than in Patient’s Home�

10- Telehealth Provided in Patient’s Home

ROI: (Release of Information)

Patient accept agree to release their Medical Information

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

The identification of the nature of an illness or other problem by examination of the symptoms.

DX-Codes means Diagnosis Code.

1. digit number. Ex: 123.45, Fever, Headage

CPT: Current Procedure Terminology

Current Procedural Terminology (CPT) is a code set that is used to report medical procedures and services to entities such as physicians, health insurance companies and accreditation organizations.

There are three types of CPT codes. Category 1 covers vaccines, Category 2 deals with performance measurement and Category 3 covers emerging technologies, services and procedures. The current version is known as CPT 2010.

HCPCS level-1 codes

Cpt Code means Procedure code. 5 digit number Procedure code include 6 types of Treatment.

1. E/M (Evaluation Management) Visit. Starting with 99201-99499.
2. Anesthesiology – Starting with 00100-01999, 99100-99140.
3. Surgery – Starting with 10021-69990.
4. Radiology (Including Nuclear Medicine and Diagnostic Ultrasound )(Ex: Exray, CT, MRI) – Starting with 70010-79999.
5. Pathalogy (Blood test, Urine test) – Starting with 80048-89356.
6. Medicine (except Anethesiology) (EKG (ECG), EMG) – Starting with 90281- 99199, 99500-99602.

HCPCS Code:

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

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

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

Level III – Local codes used by state Medicaid organizations, Medicare

contractors, and private insurers for specific areas or programs.

Pre-Existing Condition:

Patient alredy suffered from Some diesease before enter the policy, Insurance will not cover some duration for that disease, thats patient responsible thats period called “Waiting Period”.

Once the patient will complete their waiting period, insurance starts to pay their services. Ex: Heart Disease, High blood pressure, Cancer and Asthma.

FECA- Federal Employee’s Contribution Act.

The Federal Employees’ Compensation Act (FECA) provides federal employees injured in the performance of duty with workers’ compensation benefits, which include wage-loss benefits for total or partial disability, monetary benefits for permanent loss of use of a schedule member, medical benefits, and vocational rehabilitation. This Act also provides survivor benefits to eligible dependents if the injury causes the employee’s death. The FECA is administered by the Office of Workers’ Compensation Programs (OWCP)

Work on claim

1. Eligibility verification

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

1. billing entry
2. Reconcile
3. Claim submission… Paper, Electronic,Fax or Online on Web portal
4. Call after appropriate days of filing for claim status
5. If not on file verify eligibility again
6. If deny get denial reason argue them about this denial and try to reprocess if you see any possibility
7. If paid get received date. Paid date, check#, claim# and the address where they mailed the check. Date of check cleared.
8. Payment posting… and work on denial.
9. Appeal on those denials which you feel denied in error/Fault of Insurance compay or Medical Necessity.

Skills/Experience:

1. Good communication Skills.(English)

2-Knowledge of medical billing/collection practices.

1. Knowledge of computer programs and basic office equipment.
2. Knowledge of business office procedures.
3. Knowledge of basic medical coding and third-party operating procedures and Practices.
4. Ability to operate a multi-line telephone system.
5. Skill in answering a telephone in a pleasant and helpful manner.
   
6. Ability to read, understand and follow oral and written instructions.
7. Ability to establish and maintain effective working relationships with patients, employees and the public.
8. Must be well organized and detail-oriented.

DAILY USE ABBRIVATIONS

NPI– National Provider Identifier

TIN–Tax Identification Number

IVR –Interactive Voice response

EOB –Explanation of Benefits

DME –Durable Medical Equipment

HIPAA –Health insurance Portability and Accountability Act

CLIA-Clinical Laboratory Improvement Amendments.

EDI –Electronic Data Interchange.

EGHP –Employer Group Health Plan.

EIN –Employer Identification Number.

ERISA –Employee Retirement income security Act.

ESRD –End stage Renal Disease.

HCFA –Health Care Financial Administration.

HIC –Health insurance Claim.

HCPCS –Healthcare common procedure coding system.

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

DOS –Date of Service.

OWCP –Office of Worker’s Compensation Program.

PIN –Provider Identification number.

PCP –Primary Care Provider.

ERA – ElectronicRemittance Advice.

RRB– Railroad Retirement Board.

SSA –Social Security Administration.

SNF –Skilled Nursing Facility.

TPA –Third Party Administrator.

UPIN– Unique Physician Identification Number.

EVALULATION AND MANGMENT CODES(Commonly Used)

POS	LEVEL 1	LEVEL 2	LEVEL 3	LEVEL4	LEVEL5	DESCRIPTION
11	99201 10mins	99202 20mins	99203 30mins	99204 45mins	99205 60mins	OFFICENEW VISIT
	99211 5mins	99212 10mins	99213 20mins	99214 30mins	99215 45mins	SUBSEQUENT
	99241 15mins	99242 30mins	99243 40mins	99244 60mins	99245 80mins	CONSULT
13	99324 20mins	99325 30mins	99326 45mins	99327 60mins	99328 75mins	ASSISTED LIVING HOMENEW
	99334 15mins	99335 25mins	99336 40mins	99337 60mins		SUBSEQUENT
21	99221 35mins	99222 55mins	99223 70mins			HOSPITALINITIAL VISIT
	99231 15mins	99232 25mins	99233 35mins			FOLLOW UP
	99237	99238	99239			DISCHARGE
	99251 20mins	99252 40mins	99253 55mins	99254 80mins	99255 110mins	CONSULT
	99291 30-74 MINS	99292Each Additional 30 mins				HOSPITAL CRITICAL CARE
22	99234	99235	99236			SAME DAY OBSERVATION
	99218	99219	99220			INITIAL OBSERVATION
	99224	99225	99226			FOLLOW UPS
	99217					DISCHARGE
23	99281	99282	99283	99284	99285	EMERGENCY
31	99304 25mins	99305 35mins	99306 45mins			SKILLED NURSING FACILITYINITIAL VISIT
	99307 10mins	99308 15mins	99309 25mins	99310 35mins		SUBSEQUENT
	99215<30mins	99216>30mins				DISCHARGE
11	99383 5-11yrs	99384 12-17	99385 18-39	99386 40-64	99387 65More	PHYSICAL EXM New
	99393	99394	99395	99396	99397	Established

Collector Must Know(After above short training)

Must Know Basics of Medical Billing. Must Know Claim Cycle.

Must Know about Timely filing. Must know E/M codes

Must Know Place of Services.

Must Know about All Boxes of Claim form. Must Know about Main Windows of Software. Must Know about Abbreviations.

Must Know about NCCI.

Must know LCD/Medical Necessity.

Must Know BASIC process of Credentialing. Must Know to work on web portals.

Must Dial 50 calls to Hospital/Provider’s office and 50 to Insurance companies.