1. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 9 Physician Medical Billing

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Claim Forms  The patient information form is completed by a new patient at registration.  The assignment of benefits form is signed by the patient or guarantor so that the physician will be paid directly by the insurance carrier.

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Claim Forms  The release of information ensures that information will only be released to authorized entities.  The verification of benefits form with complete documentation is handy if claim is denied.

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Superbills  Contain ICD-9-CM and CPT codes for services office routinely provides  Individualized to meet specific needs of the practice  Printed by medical office specialist, attached to chart, and follows patient through visit

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Superbills  Also called encounter forms, charge slips, or routing slips  Source document for entering patient data into computerized system

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims  Claims are submitted on paper or optically scanned and converted to an electronic form by the insurance company.  Claim attachments are added to the paper claim if additional information is required.

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims  Electronic claims or electronic media claim (EMCs) are submitted via central processing unit (CPU).  Electronic form advantages include lower cost, fewer rejected claims, and faster payment.

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims  Electronic form disadvantages include disrupted transmission and inability of some billing programs to create electronic attachments.  Dirty claims have missing or incorrect data.

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500  The form was developed by Centers for Medicare and Medicaid Services to accelerate billing process.  Patient and insured information is in form locators 1–13.

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500  Physician and supplier information is in form locators 14–33.  Specific guidelines are according to payer and state and local levels.

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes HIPAA Requirements  Transaction and code sets  Uniform identifiers  Privacy  Security

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500 Instructions  Section I form locators 1–13 include patient and payer information.  Section II form locators 14–33 include physician and supplier information.  Claims without errors or missing information are “clean claims.”

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Physician Identification Numbers  Types of numbers used are state license numbers, employer identification numbers, and tax identification numbers.  NPI or National Provider Identification will be issued by Medicare and will replace identification numbers.

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Physician Identification Numbers  Referring physician (form locator 17a)  Ordering physician (form locator 17a)  Performing physician (form locator 24k)  Billing entity (form locator 33)

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Delayed or Rejected CMS-1500s  Problems are due to incorrect or missing information.  There are solutions to prevent reoccurrence of problems and delayed or denied claims.

16. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Secondary Claims  Secondary insurance covers a person in addition to primary policy.  Supplemental insurance, usually a Medigap policy, supplements Medicare payments.  Coordination of benefits occurs so that the total payment does not exceed 100% of charges.

17. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Secondary Claims  Rules exist for determining primary payer: –Lone policy –Policy in effect the longest –Birthday rule for dependent children –Certain rules regarding governmental policies –Refer to the list on pages 255–256