Thursday 14 April 2011

PreAuthorization / Prior Authorization


Prior authorization is a requirement that your physician obtain approval from your health plan to prescribe a specific treatment/service for you. Without this prior approval, your health plan may not provide coverage, or pay for you.

Pace of Services list for healthcare billing


Code(s)Place of Service Name
01Pharmacy
02Unassigned
03School
04Homeless Shelter
05Indian Health Service Free-standing Facility
06Indian Health Service Provider-based Facility
07Tribal 638 Free-standing Facility
08Tribal 638 Provider-based Facility
09-10Prison/ Correctional Facility
11Office Visit
12Home Visit
13Assisted Living Facility
14Group Home *
15Mobile Unit
16Temporary Lodging
17-19Unassigned
20Urgent Care Facility
21Inpatient Hospital Visit
22Outpatient Hospital Visit
23Emergency Room Hospital
24Ambulatory Surgical Center
25Birthing Center
26Military Treatment Facility
27-30Unassigned
31Skilled Nursing Facility
32Nursing Facility
33Custodial Care Facility
34Hospice
35-40Unassigned
41Ambulance - Land
42Ambulance  Air or Water
43-48Unassigned
49Independent Clinic
50Federally Qualified Health Center
51Inpatient Psychiatric Facility
52Psychiatric Facility-Partial Hospitalization
53Community Mental Health Center
54Intermediate Care Facility/Mentally Retarded
55Residential Substance Abuse Treatment Facility
56Psychiatric Residential Treatment Center
57Non-residential Substance Abuse Treatment Facility
58-59Unassigned
60Mass Immunization Center
61Comprehensive Inpatient Rehabilitation Facility
62Comprehensive Outpatient Rehabilitation Facility
63-64Unassigned
65End-Stage Renal Disease Treatment Facility
66-70Unassigned
71Public Health Clinic
72Rural Health Clinic
73-80Unassigned
81Independent Laboratory
82-98Unassigned
99Other Place of Service

Saturday 9 April 2011

Modifiers

A modifier indicates that a procedure was altered but its not changed its definition.


Modifiers may be used as follows:


A service or procedure has both a professional and technical component
A service or procedure was performed by more than one physician
A service or procedure has been increased or reduced
Only part of a service was performed
An additional service was performed
A bilateral procedure was performed more than once
              Unusual events occurred 


Modifier 21 - Prolonged Evaluation and Management Services (Deleted, please use CPT 99354- 99357) 

Modifier 22 -  Unusual Procedural Services

Modifier 23 -  Unusual Anesthesia

Modifier 24 -  Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period

Modifier -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

Modifier 26- Professional Component

Modifier 27 - Multiple Outpatient Hospital E/M Encounters on the Same Date

Modifier 32 -  Mandated Services

Modifier 47 -  Anesthesia by Surgeon

Modifier 50 - Bilateral Procedure

Modifier 51 - Multiple Procedures



Modifier 58 - Related service/procedure was performed  by same physician/different physician in same group during post operative period


Modifier 79 - Unrelated service/procedure was performed  by same physician/different physician in same group during post operative period


Modifier 76 - Repeat the service/procedure was performed  by same physician/different physician in same group during post operative period. It is not necessary to use in same day.


Modifier 77Repeat the service/procedure was performed  by different physician during post operative period. It is not necessary to use in same day. or service.


Modifier LT Used to identify procedures performed on the left side of the body.


Modifier RTUsed to identify procedures performed on the right side of the body.


Modifier 52 Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. 


Modifier 53Used to identify  a surgical or diagnostic procedure has been discontinued by physician under certain circumstances


Modifier 54Use with surgical codes when one physician performs a surgical procedure and another provides preoperative and/or postoperative management.


Modifier 55 -   Use with surgical codes when one physician performed the postoperative management and another physician performed the surgical procedure. 


Modifier 78- Use on surgical codes only to indicate that another procedure was performed during the postoperative period of the initial procedure.


Modifier 80Surgical assistant services may be identified by adding the modifier -80 to the usual procedure number(s)



Friday 8 April 2011

Superbill or charge sheets

Superbill or charge sheet contains the service details, physician details etc.,

It contains

*Facility Name (Location Name)
*Facility Address (Location Address)
*Facility Phone number (Location phone number)
*DOS (Date of Service)
*Attending physician Name
*Referring physician Name
*CPT (Current procedural Terminology)
*Dx (Diagnosis)
*Patient Copay details
*Mode of payment

Patient Demographic sheet



Patient Demographics sheet contains all the basic information about an individual or patient.  Patient demographics have been classified into five major headings


Patient Information
Patient employer information
Patient guarantor information
Physician information
Insurance information. 


Patient Information consists


Account #
Patient Name 
            It is entered as Last name, First Name, Middle Initial format

Patient Date of Birth 
           It is entered in the MM/DD/YYYY or MMDDYYYY as per the Billing

Sex
         It contains the Gender of the patients. i.e., M for Male, F for Female, and U                   for Unknown when the gender of the patient is not specified on the patient encounter Form. 

Patient SSN 
            It contains a 9 digit number which is allotted to the patient by the Social Security Administration.( About SSN - The President Franklin Roosevelt signed the Social Security Act on August 14, 1935. Taxes were collected for the first time in January 1937 and the first one-time, lump-sum payments were made that same month. Regular ongoing monthly benefits started in January 1940)

        Social Security numbers are assigned by Social Security Administration. SSNs were first issued in November 1936. By December 1, 2002 more than 418 million numbers had been assigned.

Patient Gender

           It contains the Marital Status of the patient. It is usually entered as ‘S’ for Single, ‘M’ for Married, ‘D’ for Divorced, ‘W’ for Widows and ‘O’ for Others. 

Patient Address:

     It is usually entered as Address1 (PO Box#/Door#/Appt. #), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code.
 
Patient phone number

       It contains the contact number of the patient including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code, and the next 7 digits are the phone number of the patient. 

Patient Employer information

It contains
Employer Code
Employer Name
Employer Address & Phone #

                        Contact details

Patient Guarantor Information

It Contains

Guarantor Name
Guarantor Address
Guarantor phone #
Guarantor/patient relationship
Guarantor employer & SSN 

Physician Information

It contains

Attending or Rendering physician name
Referring Physician/Primary Care physician name 

Insurance Information

Insurance Name
Effective Date
Subscriber's Name
Relationship Code (Option)
Subscriber Policy #

Claim Mailing address




Every information is important because it would help us to send the clean claim and get the payment immediately and will directly impact physician’s monthly revenue.  This sheet is also called as face sheet of a charge or claim. 

PPO (Preferred Provider Organization)

A combination of traditional fee-for-service and an HMO. When use the doctors and hospitals that are part of the PPO, you can have a larger part of your medical bills covered. can use other doctors, but at a high expensive. 

Maximum Out-of-Pocket Expenses


The most money you will be required pay a year for deductibles and coinsurance. It is fixed by the insurance company, in addition with  regular premiums.