Definition of Modifier 59 (What)

What is the Meaning of modifier 59?
          It is used Identify services or procedures Performed On the Same Day Due to Special Circumstances that are not Normally Reported together.
Modifier 59 - District Procedural service.

keywords  :
modifier meanings, medical billing codes

Lump Sum Purchase of DME, Prosthetics, Orthotics

For injection codes with more than one possible TOS designation, use the following guidelines when assigning the TOS:
When the choice is P or 1,

• Use TOS P if the drug is administered through durable medical equipment (DME); or
• Use TOS 1 if the drug is administered in the office.

What is CMS 1500 Claim Form?

Claim Form CMS  :

In the 1960s there were a number of different claim forms and coding systems required by third-party payers to communicate information regarding procedures and services to agencies concerned with insurance claims. However, there was no standardized form for physicians and other health care providers to report health care services. Therefore, the American Medical Association (AMA) embraced an assignment in the 1980s to work with the Centers for Medicare & Medicaid Services (CMS; formerly known as HCFA), and many other payer organizations through a group called the Uniform Claim Form Task Force to standardize and promote the use of a universal health claim form.

Although many providers now submit electronic claims, many of their software/hardware systems depend on the existing 1500 Claim Form in its current image. Minor changes have been made to the form in order to accommodate the National Provider Identifier (NPI) as well as other identifiers.

The 1500 Health Insurance Claim Form answers the needs of many health payers. It is the basic paper claim form prescribed by many health plans for claims submitted by physicians and suppliers, and in some cases, for ambulance services.

Diagnosis Related Group {DRG} Meaning

DRG is a system to classify hospital cases into one of Approximately 500 groups, also referred to as DRG'S expected to have similar hospital resource use. They have used in US since 1983. There is more than one DRG system being used in the United States, but only the MS-DRG system is used by Medicare. 

tags  :
diagnosis code meaning,

What is CPT? (CPT full form)

Definition of CPT  :
Current Procedural Terminology, is a system developed by the American Medical Association for Standardizing the terminology and Coding used to Describe medical Services And Procedures.
it is a healthcare billing code.
and easy to identification method CPT assigns a 5-digit Code to each service or procedure provide by a Physician or Provider.

Collection Process

We are sending patient statements for every 20days, within 120 days patient will not make any payment we move the claim to client’s review.

 

 Doctor office will decide whether this patient is moved to collection or not?

 

After 120 days payment not yet received from patient,  doctor office will collected the payment from patient through collection agency

 

 

Rejection Process

Insurance Rejection  :

 

Insurance received the claim and it may denied the claim because of provider# issue, patient coverage issue, etc., We need to take appropriate action.

EDI Rejection  :

While submitting the claims thru electronic via clearing house, some claims will get rejected, because of errors in claim form. We need to correct and resubmit the claim.

Insurance Types:{medical billing}

ü Federal Insurance

ü Private Insurance

ü Liability Insurance

Federal Insurance:

1. Medicare

  * Part A (Hospital Insurance)

  * Part B (Supplementary Medical Insurance)

  * Part C (Medicare + Choice)

  * Part D ( Prescription Drug)

2. Medicaid

3. CHAMPUS (Civilian Health And Medical Program for Uniform Services)

4. CHAMPVA (Civilian Health And Medical Program of Department of Veteran Services)

Private Insurance:

1.Medigap

2.IHP

3.GHP

Liability Insurance:

   * General Liability ( fire, house owner’s Risk, etc.,)

  * Auto Insurance

  * Workers Compensation Liability

Concepts of Insurance Company (Medical Billing)

1.  Traditional

  i. Basic Coverage  (In-patient service)

  Its covered technical components

  ii. Major Medical Plan (Out-patient service)

  Its covered professional component

  iii. Comprehensive Coverage (both In & Out patient service)

2.  Managed Care

HMO (Health Maintenance Organization)

POS (Point of Service)

PPO (Preferred  Provider Organization)

EPO (Exclusive Provider Organization)

Billing Terminalogy....

Medical Billing Terminalogy

1.Participating Providers

2.Non – Participating Providers

3.Capitation

4.Fee For Service (FFS)

5.Referral

6.Referral Authorization Number (RAN)

7.Pre-Authorization or Pre-Certification

8.Pre-Determination

9.Waiver of Liability

10.ABN ( Advanced Beneficiary Notice)

11.PayBack or Refund

12.Offset

13. Pre-Existing Condition

14.Waiting Period

15.COB ( Coordination of Benefits)

16.Deductible

17.Copay

18.Co-Insurance

19.Out of Pocket Expenses

20.Stop Loss Clause

21.Contract Maximum

22.Providers Identification Number

 

What is Medical Billing?

In short Medical Billing is

  “Managing Financial Transactions of the Provider”

Functions of Medical Billiing  :

The functions of a Billing offices are as follows

ü Charge Entry

ü Cash Posting

ü Accounts Receivable 

Full Processing And Ending Of Process

Insurance Claim Adjudication

  After checking the claim, if all mandatory fields are filled, Insurance Company adjudicates the claims and makes decision on the claim. The decision will be communicated to provider and also to the patient. The decision will be called as Explanation of Benefits (EOB).

  Cash posting

  Updating the payment or denial into the system. Based on the EOB Allowed amount, deductible, coinsurance, copay, other patient responsibilities, refunds, offsets will be captured.

  Denial Management

  If the EOB says it is the denied claim, the denial management team will work on the claim. The denials happen because of Patient Eligibility, Coverage issues, Credential Issues, Authorization Issues etc.,

  AR Follow up

  Accounts receivable team will follow up on Claim status, Denied claims, Appeals, Underpayment Analysis and Patient Follow ups.

  Collection Process
Incase patient is not paid the balance after repeated statements. Claim sent to collection agency to collect the balance from patient.

Medical Billing Structures (What is Medical Billing?)

What is Medical Billing?

Medical Billing is an essential part of the  
healthcare industry. Medical billing involves on submitting claims and follow up on requests to insurance companies from 
healthcare providers to receive payments 
for services rendered to patients.

In short “Managing Financial Transactions 
of the Provider”      

Medical Billing Process in Back Office Work

Demo Entry

  Entering Patient Details, Guarantor Detail, Employer Detail and Insurance Information into the system. ROI and AOB obtained in front office from patient.

  Coding:

  Assigning predefined alpha numeric codes to procedure and diagnosis. The coding department take this work. They will also undertake hospital component other than professional component. 

  Charge

  Super bill / Encounter Forms are used to capture details like Date of Service, Referring Physician, Rendering Physician, Place of Service, Type of Service, CPT Codes, ICD Codes, Modifiers, Authorization or Referral Details and Copay Details.

  Claim Submission

  Claims can be submitted through Electronic or Paper format. Paper claims sent directly to the insurance. E-Claims initially sent to clearing house. Clearing house converts into insurance specific format and dispatch to the insurance.

Types Of Insurance (Medical Billing)

Insurance Types

1 Federal Insurance

2 Private Insurance   3 Liability Insurance

lFederal Insurance:

l1. Medicare

l  * Part A (Hospital Insurance)

l  * Part B (Supplementary Medical Insurance)

l  * Part C (Medicare + Choice)

l  * Part D ( Prescription Drug)

l2. Medicaid

l3. CHAMPUS (Civilian Health And Medical Program for Uniform 

Services)

 

l4. CHAMPVA (Civilian Health And Medical Program of   

 Department of Veteran  Affairs)

 

lPrivate Insurance:

lMedigap

lIHP

lGHP

lLiability Insurance:

l* General Liability ( fire, house owner’s Risk, etc.,)

l* Auto Insurance

l* Workers Compensation

Concepts of Insurance Company

1.  Traditional

  i. Basic Coverage (In-patient service)   
  It Covers technical components
  ii. Major Medical Plan (Out-patient service)

  It Covers professional component
  iii. Comprehensive Coverage (both In & Out patient service)

2.  Managed Care

HMO (Health Maintenance Organization) Patient must meet PCP. Then he will refer to a specialist. Referral Authorization Number is essential.

POS (Point of Service) After meeting the PCP Patient can choose specialist from the list of providers . Out of Network Providers Covered.

PPO (Preferred  Provider Organization) Directly patient can go to the specialist. Out of Network Providers Not Covered.

EPO (Exclusive Provider Organization) Except Emergency Cases Out of Network Providers Not Covered.