MEDICAL BILLING

What is Medical Billing

It is the process of sending the Claim forms (CMS 1500 foam) to the Insurance
company on behalf of the provider office.

EOB (Explanation Of Benefits)

It is the statement received from the insurance company after submitting a claim form.

ERA (Electronic Remitance Advice)

It is a electonic format of EOB.

DENIAL
It is a statement received from insurance company stating that they are not going to
pay the claim and the statement is called denial.
OR
It is the information mentioned in denied claim EOB.
CPTCODE (OR) CURRENT PROCEDURAL TERMINOLOGY
The treatment done by the provider to the patient is converted in to alpha numeric code
is called “CPTCODE” .
Range is 5 digits.
( OR )
IT REPRESENTS PROVIDER SERVICE
CPT CODE MENETIONED IN CMS 1500 --- BLOCK NO 24 D

REFERENCE BOOK
Healthcare Common Procedure Coding System (HCPCS).
It is the codes which specifies range for a speciality of provider
CPT Code Ranges and Values:
Office Visit : 99202 - 99215
EM (Evaluation and management service): 99201 - 99215
New Patient Cpt Codes : 99201 – 99205
Established Patient CPT Codes : 99211 - 99215
Anesthesia : 00100 - 01999
Surgery : 10000 – 69990
Radiology : 70010 - 79999 (X-ray , scanning)
Laboratory : 80000 - 89999

DIAGNOSIS CODE OR DX CODE

The disease or illness of the patient is converted in to alpha numeric code is called
“DIAGNOSIS CODE ” it’s range is Upto 7 digits.
( OR )
IT REPRESENTS PATIENT DISEASE
REFERENCE BOOK

ICD 10CM (International classification of disease of 10th revision clinical modification).

It is effective from october 2015 before that ICD9CM.
DOS (Date of Sevice )

It is the date when the treatment was taken by patient .

DOS MENTIONED IN CMS 15000 - Block 24A
REVENUE CYCLE MANAGEMENT
The total process from Retriving of files to AR follow up is called "RCM".
CAN U EXPLAIN RCM FOR ME OR CAN U PLEASE TELL ME THE STEPS
INVOLVED IN RCM?
ANS : It include process like
• Patient Demographics
• Medical coding
• Charge entry
• Cash Posting
• AR Followup – AR Caller

MODIFIER
It is alpha numeric code that gives extra meaning to the cpt code.
BLOCK NO IN CMS 1500 FORM - BLOCK NO 24 D

What are the modifiers you used in your previous office or tell me some modifiers
what you know ?
ANS . We have used modifiers
24 – It is defined as an unrelated evaluation and management
service by the same physician
26 - It represents physician services and it is most commonly submitted with
diagnostic tests, including radiological procedures
TC – It represents technical component service
LT – It represents service done for left side organ of body
RT - It represent service done for Right side organ of body
50 – Bilateral services (Both sides organ of the body)
 51 - It indicates that a second procedure was performed, and it is not a component
code of the first procedure
57 - It is used to indicate an Evaluation and Management (E/M) service resulted in the
initial decision to perform surgery either the day before a major surgery (90 day global)
or the day of a major surgery.
59 - It it is distinct service ( used for 0 to 8 starting cpt codes)
25 - It it is distinct service (used for 9 series cpt codes)
76 - It represents represents same service done twice by same provider
77 - It represents same represents service done twice by differenet provider
Social Security Number (SSN)
It is a nine digit unique number issued to US citizens (permanent residents and
temporary working residents.)
Format is 854- 46- 7896
Primary Care Physician (PCP)
PCP is the provider who provides initial care and refer the patient to the other provider
for special services.
BLOCK NO WHERE IT IS MENTIONED IN CMS 1500 - BLOCK NO 17
National Provider Identifier (NPI)
It is a 10 digit number given for every US provider by US government.
RENDERING PROVIDER NPI NUMBER IN CMS 1500 - BLOCK NO 24J
REFERRING PROVIDER OR PCP NPI NUMBER IN CMS 1500 - BLOCK NO 17B
TAX ID
Tax payer identification number (TIN) It is a 9 digit unique number given for every
provider by US government.
TAX ID NUMBER IN CMS 1500 FORM - BLOCK NO 25

BILLLED AMOUNT (OR) CHARGED AMOUNT (OR) TOTAL AMOUNT

It is the total amount charged for a claim service.
BILLED AMOUNT IN CMS 1500 FORM -- BLOCK NO 28
FEE SCHEDULE
It is the document that gives the cost for each cpt code.
ALLOWED AMOUNT
The maximum amount fixed by the insurance company for a CPT code is based on the
insurance fee schedule.
Paid Amount
It is the amount paid to the provider by insurance.
Patient Responsibility
It is the amount patient has to pay.
It is Co- Insurance, Co-Pay, and Deductible.
Deductible
Patient has to satisfy certain amount which was fixed by insurance company after
satisfying that amount only insurance will pay for his medical benefits.
Copay
It is the initial amount paid to the provider before taking the service by patient
Co Insurance
It is patient responsibility that patient has to pay if there is no secondary insurance.
INSURANCE
Primary Insurance
It is the insurance that is first responsible for making payments to the providers.
Secondary Insurance
It is the insurance that is second responsible for making payments to the provider after
the primary insurance.
,Teritiary Insurance
It is the insurance responsible for making the payments after secondary insurance.
Co ordinate Benefit
Patient has to decide who is primary and who is secondary before taking policy .
Allowed amount = paid amount + patient responsibility
Paid amount = allowed amount - patient responsibility
Medicare
It provides health care benefits for the people who are above age 65, who is physically
handicapped people and who is suffering from (ESRD) End Stage Renal Disease.
What are the plans involved in MEDICARE
They are four types of plan in Medicare they are
Medicare Part A : Hospital coverage or It will cover inpatient
Medicare Part B : Physician services or Outpatient
Medicare Part C : Medicare advantage plan (instead of Medicare other commercial
insurances will pay)
Medicare Part D : Medicines or Drugs
Medicare cross over claim
The automatic transfer of a claim from primary medicare to the patient’s secondary
payer is known as medicare crossover (or) piggyback claims.
Medigap Policy
Medigap policy is also known as “Medicare Supplemental Plan”.
 It is always pay as secondary.
 It will not pay for copay,co-insurance,deductible.
 It will cover only one person.
Railroad Medicare
It is Medicare program offered to retired railway employees (who are above 65).
What is TFL for Medicare?
TFL for Medicare 1 year
MEDICARE PART B ANNUAL DEDUCTIBLE AMOUNT
 $198.00 for 2020
 $ 203.00 for 2021
MEDICARE PREMIUM
 $148.50 For 2021
 $144.60 For 2020
Medicare insurance id looks like
Previously It Is a SSN# followed by suffix and now it is changed to Alpha numeric code.
SSN# - 452 -30 -8619
Previous Medicare Id- 452308619A
Present Medicare Id - MRXT5H99
IN WHAT CASES MEDICARE WILL PAY AS SECONDARY INSURANCE
1 Worker Compensation
2. Auto Insurance
3. Veterans Administration insurance
Medicaid
It will provides the health care benefits for the people who are below poverty line ,
pregnant women , people with disability.
Medicaid spend down program (Or) Medicaid spend down cost (SDC)
(Or) Share On Cost (SOC)
If a person earnings totally spent on health care expenses he is eligible for medicaid
spend down program.
Tricare
It will provides the health care benefits for Uniformed people and their families and
retired employees.
OR
It is a regionally managed healthcare program for active duty & retired members of the
uniformed services and there families.

CHAMPVA Or CHAMPUS
It will provides health care benefits for the spouse or child of a veteran who has been
rated permanently and totally disabled for a service connected disability.
It provide healthcare benefits for Dependents of Veterans.
Work Compensation
It will provide the health care benefits for the employee who subjected to illness or
accidents which happens during the work time.
(OR)
It will provide the health care benefits for the employee( who become ill or injured in
worked time)
Advance Beneficiary Notice
It is a notice sent to patient by provider when they believe this service will not cover by
Medicare.
PTAN
Provider Transaction Access Number (PTAN) is a number issued to providers by
Medicare, after enrolling with Medicare

Commercial Insurance
• UHC +1-877-842-3210 TFL 90 Days
• AETNA 1 800-624-0756 TFL 120 Days
• CIGNA 1 800-102-4464 TFL 90 Days
• HUMANA 1 800-457-4708 TFL 180 Days For (Physicians)
90 Days For (Ancillary Providers)
• BLUE CROSS BLUE SHIELD (BCBS) TFL 90 Days

Place of service
It is the place were service is rendered.
Tele Health - 02
Office visit – 11
Home - 12
In patient - 21
Out patient -22
Emergency - 23
Ambulatory services -24
Skilled Nursing Facility- 31
Nursing Facility – 32
Hospice – 34
Ambulance (Land) – 41
Ambulance (Air & Water) - 42
POS MENTIONED IN CMS 1500 -- Block 24B
Physical Address or Facility –
it is place where provider office or facility is located.
FACILITY MENTIONED IN CMS 1500 -- BLOCK NO 32
Billing address
it is place where EOB and cheques are sent by insurance company .
POS MENTIONED IN CMS 1500 -Block 33
Clearing House
It is an Middle office between provider and insurance company.
What is the clearing house you are using in previous office?
GATEWAY
Rejection
claims will be returned from Clearing office or insurance company is called rejection.
PAYMENT WILL BE MADE IN THREE WAYS:
1 CHEQUE
2. EFT( Electronic fund transfer)
It is way of transferring fund electrically.
3. CREDIT CARD OR DEBIT CARD
Charge Sheet or SuperBill
Simply it is called medical records.
It contain details of provider name, Date of service,disease and service details.
HIPAA (Health insurance portability and accountability act)
It is Law implemented in 1996 by CMS. It is used to protects health records from third
party.
Appeal
A formal request sent to insurance company asking to reprocess the claim.
Reprocess
If insurance denied claim incorrectly we are asking to reverify the claim to get the
payment it is called Reprocess
CMS
Centre For Medicare and Medicaid service.
HCFA
Health care financing administration. formerly known as CMS
Assignment of Benefits (AOB) - It is an legal agreement between patient and
insurance company to release funds to the provider.
AOB MENTIONED IN CMS 1500 --- BLOCK NO 13
Release of Information (ROI) - It is agreement between patient and provider to release
patient health information to insurance company.
ROI MENTIONED IN CMS 1500 --- BLOCK NO 12
Claim will be sent in 3 ways
1.Electronic payor id
2.mailing address
3.fax#
MEDICARE INSURANCE YOU WIL TRANSFER THE CLAIMS ELECTRONICALLY
OR THRU MAILING ADDRESS?
ANS : ELECTRONICALLY

MANAGED CARE PLANS:

 Managed care plans are mainly introduced to give better health benefits plan at
affordable price and also to avoid patient’s misuse of the policy.
 Co-pay was introduced in managed care plan .
  Network and PCP concept applicable.
 Preventative service are covered.
 Authorization concept has been introduced.
 Premium is less compared to indemnity/traditional plan.

TYPES OF MANAGED CARE PLANS:

They are four types of managed care plans they are
1 HMO (Health Maintainence Organization)
2 PPO (Preferred Provider Organization)
3 EPO (Exclusive Provider Organization)
4 POS (Point Of Service)

HMO PP EPO POS

O
PCP YES NO YES YES
REFERRAL YES NO YES YES
INNETWORK YES YES YES YES
OUTNETWORK NO YES NO YES
AUTHORIZATIO YES YES YES YES
N

HMO PLAN

IT IS MANAGED CARE PLAN

• IF WE TAKE HMO PLAN PCP IS COMPULSARY AND REFERAL IS
COMPULSARY
• NEED TO VISIT INNETWORK PROVIDER AND OUTNETWORK NOT
ELIGIBLE
• AUTH IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIM

PPO PLAN
IT IS MANAGED CARE PLAN
 • IF WE TAKE PPO PLAN PCP AND REFERAL IS NOT NEEDED .
• INNETWORK AND OUTNETWORK PROVIDERS ELIGIBLE
• AUTH IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIM
EPO PLAN
IT IS MANAGED CARE PLAN
• IF WE TAKE EPO PLAN PCP IS COMPULSARY AND REFERAL IS
COMPULSARY
• NEED TO VISIT INNETWORK PROVIDER AND OUTNETWORK NOT
ELIGIBLE
• AUTH IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIM
POS PLAN
IT IS MANAGED CARE PLAN
• IF WE TAKE HMO PLAN PCP IS COMPULSARY AND REFERAL IS
COMPULSARY
• AUTH IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIM

PTAN
IT IS THE NUMBER GIVEN FOR EVERY US PROVIDER AFTER REGISTERING
WITH MEDICARE INSURANE
CORRECTED CLAIM
After making Necessary changes in claim form it is considered as CORRECTED
CLAIM.
HOW YOU WILL SUBMIT CORRCTED CLAIM?
After making necessary changes I will type CORRECTED CLAIM in 19 TH BLOCK and
I will submit to insurance company.

W9 Form
W9 form is used for updating the provider billing office address and provider related
information with insurance.
Date Of Birth
According to date of birth rule for a child primary and secondary insurance is selected
(when mother and father is having insurance)
Mother 02/09/1992
Father 06/27/1990
In this case according to month decision is taken not year
Hence, Mother insurance is primary and father is secondary

Beneficiary OR Insured Person

A person eligible for receiving benefits under insurance policy. He is also called as
subscriber.
HOSPICE
It provides Medical care and Treatment for persons who will be dying soon.
AGING
Aging report is useful for catching charges that are going unpaid. It has breakdown of
aging bucket and it is calculated from dos.
30 FRESH CLAIM
30-60 1 ST FOLLOWUP
60-90 2ND FOLLOWUP
90-120 3RD FOLLOWUP
120+ FOLLOWUP