Page 1 of 16 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 biling claim. The responsibility of the medical biller in a health care facilty is to follow that claim to ensure the practice receives reimbursement for the work the providers perform. A knowledgeable biller can optinize revenue performance for the practice, Although a medical biller's duties vary with the size of the work faciity, 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 Il and ICD-9-CM codes, 1 Medicare Medicaid 3. Tricare 4. RR Medicare (RR-Rail Road) Medicare Eligible Administrated by_administered directly the federal government. 1 People 65 Years above 2. People Under 65 with certain Disabilities For People with Disabilities and Illnesses No matter how old you are, if you have Lou Gehrig's disease, kidney failure, or certain other disabilities, you are eligible for Medicare. But you might have a waiting period before you can get Medicare benefits. Here are the details. Lou Gehrig's disease (ALS). As soon as you get Social Security Disability benefits for ALS, you should be automatically enrolled in Medicare. There is no waiting period. Kidney failure. To qualify, you must have end-stage renal disease and need dialysis ora kidney transplant, Usually, you can't get Medicare until three months after you start dialysis. Once Cyber System Medical Billing, 23 Fane RD Mazang Adda. Lahore. Pakistan.Page 2 of 16 MEDICAL BILLING TRAINING MANUAL you've been diagnosed with kidney failure, call the Social Security administration at (800) 772- 1213 to enroll in Medicare. Other disabilities for which you get Social Security Disability benefits. You can't get Medicare until two years after you qualify for Social Security Disability. At that point, the Social Security Administration should sign you up automatically Note: Patient must be Tax Paid in order to get Medicare benefits. ‘The Dit {Medi Part A Part B Part C Part D Part A (Hospital Insurance) Only Covered with Hospital Services. ( Ex. Bed Charges & Equipment charges) Its Cover Inpatient care in Hospital. Its cover Skilled Nursing facility, hospice and home health care. Claims billing to UB92 & UB04 forms: Part B (Medi surance Its Covered with Doctors’ Services, hospital outpatient care and home health care. Its cover some Preventive services to help maintain your health and to keep certain illness from getting worse Claims Billing to HCFA-1500 & CMS1500 forms. Part C (PartA+PartB+PartD) Medicare Advantage plans (like an HMO or PPO) are health plans run by Medicare-approved private insurance companies. Medicare Advantage plans (also called Patt C) include Part A, Part B and usually other coverage like Medicare prescription drug coverage (Part D), sometimes for an extra cost Part D ( Medicare prescription Drug Coverage) Only Covered with Drug Programme ( supply for Medicine) Ex: Sugar Patient Here's what the letters behind the Medicare number mean: *A = retired worker B = wife of retired worker B1 = husband of retired worker Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 3 of 16 MEDICAL BILLING TRAINING MANUAL B6 = divorced wife B9 = divorced second wife C = child of retired or deceased worker; numbers after C denote order of children claiming benefit D = widow dower surviving divorced wife E = mother of a child of a deceased worker E1 = divorced mother of a child of a deceased worker F1 = aged dependent father F2 = aged dependent mother *HA = disabled worker HB = wife of disabled worker child of disabled worker special “over 72” benefit, has A and B fe of ‘over 72” benefit, has A and B 1as Part B Medicare only, no SSA benefit *T = has A and B Medicare, no SSA benefit W = disabled widow WA = railroad retirement * denotes the recipient's own social security number. Medicaid: It’s Covered with below Poverty people (or) Low income people. It’s monthly month basic Administrated by Each State Law. Dual Eligible Medicare Beneficiary Groups Dual Eligible Income Medicare Criteria Benefits Beneficia Groups Eligible for Medicaid ipo ot payment of Medicare premium, deductible, the Federal QMB coinsurance and Poverty Line tre copayment amounts (except for Medicare Part D). Entitled to all benefits available to a QMB, *< 100% of ame Plus** err as well as all benefits available under the State Medicaid plan. Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.MEDICAL BILLING TRAINING MANUAL SLMB Only* specfied ow. | > Tree Eligible for payment of Income e opieet Medicare Part B Medicare . premiums only. the FPL Beneficiaries Sacer Entitled to all benefits tha FPL but available to an SLMB, as SLMB Plus** pei well as all benefits the FFL available under the State Medicaid plan Eligible for payment of sient Medicare Part 8 Qi premiums only; however, the FPL but Qualifying eiemct expenditures are 100% Individuals ° federally funded and total the FPL expenditures are limited by statute. apwi Qualified anon or Eligible for Medicaid Disabled payment of Medicare Part the FPL Working Apremiums only. Individuals Eligible for Medicaid either categorically or through optional coverage FeDE NA groups, such as Medically Needy or special income levels for institutionalized or home and community based waivers. Tricare: It’s Coved with Army people. Tricare Two Types: Page 4 of 16 1 CHAMPVA ( Civilian Health and Medical program for Veteran affairs) 2 CHAMPUS ( Civilian Health and Medical program for Uniformed services) RR Medicare: It’s covered with Railway Department, Transport Department & Highway’s Department which is part of Railways. Palmetto GBA is the Railroad Specialty Medicare Administrative Contractor (RRB SMAC) and processes Part B claims for Railroad Retirement beneficiaries nationwide, Cyber System Medical Billing ‘2 Ree BP brs Been inne, Gibieten.Page 5 of 16 MEDICAL BILLING TRAINING MANUAL Worker's Compensation It’s covered with Work related injury and work relevant accident Auto Accident It's Covered with Vehiele Accident ‘Two types of Auto Accident: No fault Auto Accident 2. Non-No fault Auto Accident zed Care Plan: To provide High quality service at low Ca 1.HMO (Health Maintenance Organization) Patient must goes to in-network Provider. PCP Must. (Low premiums, low deductible, copay & coins). PCP means Primary care Physician. Pt goes to PCP first and PCP Issue Referral for specialist visit according to Diagnose. 2. PPO (Preferred Provider Organization) Patient may go to any Healthcare Provider in listed Panel doctors, anywhere: Include out of Network If benefits are available. 3. EPO (Exclusive Provider Organization) Similar to an HMO, with an EPO you must use network providers - doctors, hospitals and other health care providers - that participate in the plan. The only exception is for emergency care. Unlike an HMO, you do not need to select a Primary Care Physician, nor do you need to contact your PCP for referrals to specialists 4. POS (Point of Services) It’s companied with HMO+PPO Patient goes to any network provider (In or Out). PCP Must POS plans combine elements of both HMO and PPO plans. Like an HMO plan, you may be required to designate a primary care physician who will then make referrals to network specialists when needed. Depending upon the plan, services rendered by your PCP are typically not subject to a deductible and preventive care benefits are usually included. Like a PPO plan, Cyber System Medical Billing ‘A Pare WD Mivanie Acts Lshore. Pakdictari.Page 6 of 16 MEDICAL BILLING TRAINING MANUAL you may receive care from non-network providers but with greater out-of-pocket costs. You may also be responsible for co-payments, coinsurance and an annual deductible ‘Traditional Indemnit subject to deductible ratients are billed and repaid for all or part of each service performed, 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 HSA: Health savings accounts (HSAs) are like personal savings accounts, but the money in them is used to pay for health care expenses. You — not your employer or insurance company — own and control the money in your health savings account. The money you deposit into the account is not taxed. To be eligible to open an HSA, you must have a special type of health insurance called a high-deductible plan, PAR Provid (Participating Provider) Who agrees and pt Insurance fees schedule and willing to contract with Insurance company. Capitation: 1. Fixed Capitation 2. Rolling Capitation Il Fixed Capitation: Provider will be get fixed amount for every month/year. 2. 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). Cyber System Medical Billing, 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 7 of 16 MEDICAL BILLING TRAINING MANUAL Medical Terminology Coinsurance: Portion/Fixed Percentage of the Allowed amount, insured/subscriberPatient has to pay to Healthcare Provider. Copay It's fixed amount payable to provider by insured for each visit. Deductible: A specified amount of money that the insured must pay before an insurance company starts benefits. Medicare & Commercial insurance starts in January of each year Tricare insurance starts in October of each year 2009 PART-B annum Deductible amount - $135.00 2010 PART-B annum Deductible amount - $150.00 2011 PART-B annum Deductible Amount -$162.00, 2012 PART-B annum Deductible Amount -$140.00, 2013 PART-B annum Deductible Amount -$147.00 Auth ‘Two types of Authorization \ 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. Referral: A referral is 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 OB: (Assignment of Benefits! Patient assigned benefits to the provider behalf of the treatment. Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 8 of 16 MEDICAL BILLING TRAINING MANUAL COB: Coordination of Benefits Its details of 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 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 It the provider not refund the amount in the insurance company bill be adjusted on the next Claim. Modifier: Modifiers are codes that are used to “ENHANCE OR ALTER THE DESCRIPTION OF A SERVICE OR SUPPLY” UNDER CERTAIN CIRCUMSTANCES. A modifier 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. The judicious application of modifiers obviates the necessity for separate procedure listings that may describe the modifying circumstance. 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 physi location. an and/or in more than one A service or procedure has been increased or reduced, Only part of a service was performed. A bilateral procedure was performed. Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 9 of 16 MEDICAL BILLING TRAINING MANUAL A service or procedure was provided more than once. Unusual events occurred. Information Modifier Reimbursement Modifier Does not Vary the payment just intimate the insurance company which part of the organ service was rendered eg.LT, RT, Al, KX, KO 2, Reimbursement Modifier: Vary the payment who render the service patient (EX) PC, TC, 24,25,26,59,78,79 ‘ommonly User Modifier: 24::Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service 26: Reading of Reports. 50: Bilateral Procedure. iB Decision of Surgery 58: Staged or Related Procedure or Service by the Same Physician During the Postoperative Period 59: Distinct Procedural Service 76: Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated Subsequent to the original procedure or service 71: Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 10 of 16 MEDICAL BILLING TRAINING MANUAL 79:Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure 90: Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier 90 to the usual procedure number. 91: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment: or for any other reason when a normal, one-time. reportable result is all that is require Centers of Medicare and Medicaid Service HIPAA: HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. HIPAA does the following + Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs: + Reduces health care fraud and abuse: + Mandates industry-wide standards for health care information on electronic billing and other processes: and + Requires the protection and confidential handling of protected health information POS: (Place of Service) It’s Indicate where the service was rendered. (EX) Hospital .Clinic, Home ete. Most commonly used POS are mentioned below 11-Office 12-Home —_13-Assisted Living Facility 20-Urgent Care 21-Hospital In Patient Hospital Out Patient 23-Emergencey Room 31-Skilled Nursing Facility 32-Nursing Facility 81-Independent Laboratory ROL; (Release of Information) Patients accept agree to release their Medical Information The identification of the nature of an illness or other problem by examination of the symptoms. DX-Codes means Diagnosis Code. 3-5 digit numbers. Ex: 123.45, Fever, Headache CPT: Current Procedure Terminology Cyber System Medical Billing 3 Fane RD Mazane Adda, Lahore, Pakistan.Page 11 of 16 MEDICAL BILLING TRAINING MANUAL 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 | 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 codes 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. Pathology (Blood test, Urine test) — Starting with 80048-89356 6. Medicine (except Anesthesiology) (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 Conditio1 Patient already suffered from Some disease before enter the policy, Insurance will not cover some duration for that disease, that patient responsible... that 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 Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 12 of 16 MEDICAL BILLING TRAINING MANUAL eligible dependents if the injury causes the employee's death. The FECA is administered by the Office of Workers’ Compensation Programs (OWCP) Hospice Care Hospice care is end-of-life care. A team of health care professionals and volunteers provides it They give medical, psychological, and spiritual support. The goal of the care is to help people who are dying have peace, comfort, and dignity, The caregivers try to control pain and other symptoms so a person can remain as alert and comfortable as possible. Hospice programs also provide services to support a patient's family. Usually, a hospice patient is expected to live 6 months or less. Hospice care can take place At home Ata hospice center Ina hospital Ina skilled nursing facility Billing Forms There are two main forms for billing claims. The first is called CMS-1500, which is the main billing form to submit physician claims, The second is called a UB-04, which is used to submit hospital claims. Medicaid uses its own type of billing form, which differs from state to state, and also from service to service sometimes. All of these types of insurance, and many others, will accept claims electronically, which saves you from having to figure out which forms to use There are still many types of insurance that will require a paper claim, though. Work on claim 1. Eligibility verification Pt. id/group number. effective/Termination date, claim mailing address, payer ID or fax, Timely filing limit. 2. Billing entry 3. Reconcile 4. Claim submission... Paper. Electronic, Fax or Online on Web portal 5. Call after appropriate days of filing for claim status 6. If not on file verify eligibility again 7. Ifdeny get denial reason argue them about this denial and try to reprocess if you see any possibility 8. If paid get received date, Paid date, check#, claim# and the address where they mailed the check. Date of check cleared. 9. Payment posting... and work on denial 10. Appeal on those denials which you feel denied in error/Fault of Insurance company or Medical Necessity Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 13 of 16 MEDICAL BILLING TRAINING MANUAL Skills/Experience: 1. Good communieation/Listening Skills.(English) 2-Knowledge of medical billing/collection practices. Knowledge of computer programs and basic office equipment. . Knowledge of business office procedures. Knowledge of basic medical coding and third-party operating procedures and Practices. Ability to operate a multi-line telephone system. Skill in answering a telephone in a pleasant and helpfull manner, Ability to read, understand and follow oral and written instructions. Ability to establish and maintain effective working relationships with patients. employees and the public. 10. 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 - Electronic Remittance Advice RRB - Railroad Retirement Board. SSA - Social Security Administration SNF - Skilled Nursing Facility. TPA - Third Party Administrator. UPIN - Unique Physician Identification Number. Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 14 of 16 MEDICAL BILLING TRAINING MANUAL EVALULATION AND MA) TENT CODES(Commonly Used. pos | tevela | vevel2 | vevers | tevela | Levers | DESCRIPTION 99201 | 99202 | 99203 | 99204 | 99205 | OFFICE 1 2omins_| 20mins_| 30mins | aSmins_| 60mins_| NEW VISIT 99211 | 99212 | 99213 | 99214 | 99215 mins | 10mins_| 20mins_| 30mins_| a5mins_| SUBSEQUENT 99241 | 99242 | 99243 | 99244 | 99245 1smins_| 30mins_| 40mins_| 60mins_| 80mins_| CONSULT ‘ASSISTED 99324 | 99325 | 99326 | 99327 | 99328 | LIVINGHOME 2omins_| 30mins_| asmins | 6omins | 75mins_| NEW 99334 | 99335 | 99336 | 99337 1smins_| 25mins_| 4omins_| 6omins SUBSEQUENT 99221 | 99222 | 99223 HOSPITAL 35mins_| s5mins_| 70mins INITIAL VISIT 99231 | 99232 | 93233 15mins_| 25mins_| 35mins FOLLOW UP 99237_| 99238 | 99239 DISCHARGE 99251 | 99252 | 99253 20mins_| admins _| 5Srmins CONSULT ‘99292 99291 | gach 30-74 | additional an mins | 30.mins CRITICAL CARE SAME DAY 99234_| 99235 OBSERVATION INITIAL, 99218 | 99219 OBSERVATION 99224 _| 99225 FOLLOW UPS 99217 DISCHARGE 99281 EIMERGENCY SKILLED NURSING 99304 | 99305 | 99306 FACILITY 25mins_| 35mins_| 45mins INITIAL VISIT 99307 | 99308 | 99309 tomins_| 1smins_| 25mins SUBSEQUENT 99215 | 99216 <30mins | >30mins DISCHARGE 99383 | 99384 | 99385 | 99386 | 99387 | PHYSICAL EXM s-iiyrs | 12.17 | 18-39 | 40-64 _| 65More | New 99393_| 99394 | 99395 | 99396 | 99397_| Established Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 15 of 16 MEDICAL BILLING TRAINING MANUAL NEW PATIENT VISIST Required Key Component 3/3 99201 | 99202 | 99203 | 99204 | 99205 - Problem-Focused x - Expanded Problem-Focused x Detailed x - Comprehensive x x Medical Decision Making (complexity) «Straightforward x x -Low x - Moderate x - High x Contributory Factors Presenting Problem (Severity) - Self-Limited or Minor x - Low to Moderate x - Moderate x - Moderate to High x x ISHED PATIENT. Required Key Component 3/3 g9211 | 99212 | 99213 | 99214 | 99215 - Problem-Focused NA - Expanded Problem-Focused x - Detailed x - Comprehensive x x Medical Decision Making (complexity) Straightforward NA x Low x - Moderate. x “High x Contributory Factors Presenting Problem (Severity) Self-Limited or Minor x Low to Moderate x - Moderate x + Moderate to High x x Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.Page 16 of 16 MEDICAL BILLING TRAINING MANUAL Collector Must Know(After above short training Must Know Basics of Medical Billing. Must Know Claim Cyele 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, Insurance Companies and Patients. Cyber System Medical Billing 3 Fane RD Mazang Adda, Lahore, Pakistan.