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.
Thursday 14 April 2011
Pace of Services list for healthcare billing
| Code(s) | Place of Service Name |
| 01 | Pharmacy |
| 02 | Unassigned |
| 03 | School |
| 04 | Homeless Shelter |
| 05 | Indian Health Service Free-standing Facility |
| 06 | Indian Health Service Provider-based Facility |
| 07 | Tribal 638 Free-standing Facility |
| 08 | Tribal 638 Provider-based Facility |
| 09-10 | Prison/ Correctional Facility |
| 11 | Office Visit |
| 12 | Home Visit |
| 13 | Assisted Living Facility |
| 14 | Group Home * |
| 15 | Mobile Unit |
| 16 | Temporary Lodging |
| 17-19 | Unassigned |
| 20 | Urgent Care Facility |
| 21 | Inpatient Hospital Visit |
| 22 | Outpatient Hospital Visit |
| 23 | Emergency Room Hospital |
| 24 | Ambulatory Surgical Center |
| 25 | Birthing Center |
| 26 | Military Treatment Facility |
| 27-30 | Unassigned |
| 31 | Skilled Nursing Facility |
| 32 | Nursing Facility |
| 33 | Custodial Care Facility |
| 34 | Hospice |
| 35-40 | Unassigned |
| 41 | Ambulance - Land |
| 42 | Ambulance Air or Water |
| 43-48 | Unassigned |
| 49 | Independent Clinic |
| 50 | Federally Qualified Health Center |
| 51 | Inpatient Psychiatric Facility |
| 52 | Psychiatric Facility-Partial Hospitalization |
| 53 | Community Mental Health Center |
| 54 | Intermediate Care Facility/Mentally Retarded |
| 55 | Residential Substance Abuse Treatment Facility |
| 56 | Psychiatric Residential Treatment Center |
| 57 | Non-residential Substance Abuse Treatment Facility |
| 58-59 | Unassigned |
| 60 | Mass Immunization Center |
| 61 | Comprehensive Inpatient Rehabilitation Facility |
| 62 | Comprehensive Outpatient Rehabilitation Facility |
| 63-64 | Unassigned |
| 65 | End-Stage Renal Disease Treatment Facility |
| 66-70 | Unassigned |
| 71 | Public Health Clinic |
| 72 | Rural Health Clinic |
| 73-80 | Unassigned |
| 81 | Independent Laboratory |
| 82-98 | Unassigned |
| 99 | Other 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:
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 77 - Repeat 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 RT - Used 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 53 - Used to identify a surgical or diagnostic procedure has been discontinued by physician under certain circumstances
Modifier 54 - Use 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 80 - Surgical assistant services may be identified by adding the modifier -80 to the usual procedure number(s)
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 77 - Repeat 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 RT - Used 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 53 - Used to identify a surgical or diagnostic procedure has been discontinued by physician under certain circumstances
Modifier 54 - Use 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 80 - Surgical 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
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 Information
Patient employer information
Patient guarantor information
Physician information
Insurance information.
Patient Information consists
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
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.
Managed Care
It is to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care.
HMO (Health Maintenance Organization)
It is prepaid health plans. You needs to pay a monthly premium and it covers your doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You should use the doctors and hospitals designated by the HMO plan
Deductible
The premium amount must pay each year by patient to cover the medical care expenses before insurance policy starts effective.
Copayment
It is another way of sharing medical costs by patient. Patient needs to pay a flat fee to doctor for every time they receive a medical service(for example, $10 for every visit to the doctor). It is fixed by Insurance company
Coinsurance
The amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.
Sunday 27 March 2011
2011 CPT changes in Interventional cardiology
- 93451 - RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT
- 93452 - L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I
- 93453 - R & L HRT CATH W/NJX L VENTRICULOG IMG S&I
- 93454 - CATH PLMT & NJX CORONARY ART ANGIO IMG S&I
- 93455 - CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I
- 93456 - CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I
- 93457 - CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I
- 93458 - CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I
- 93459 - CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I
- 93460 - R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I
- 93461 - R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I
- 93462 - LEFT HEART CATH BY TRANSEPTAL PUNCTURE
- 93463 - MEDICATION ADMIN & HEMODYNAMIC MEASURMENT
- 93464 - PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE
- 93563 - NJX SEL HRT ART CONGENITAL HRT CATH W/S&I
- 93564 - NJX SEL HRT ART/GRFT CONGENITAL HRT CATH W/S&I
- 93565 - NJX SEL L VENT/ATRIAL ANGIO HRT CATH W/S&I
- 93566 - NJX SEL R VENT/ATRIAL ANGIO HRT CATH W/S&I
- 93567 - NJX SUPRAVALV AORTOG HRT CATH W/S&I
- 93568 - NJX PULMONARY ANGIO HRT CATH W/S&I
- 95800 - SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME
- 95801 - SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL
- 96446 - CHEMOTX ADMN PRTL CAVITY PORT/CATH
PECOS
Provider Enrollment, Chain, and Ownership System (PECOS)
Providers and suppliers must have Internet Explorer version 5.5 or higher and have the most recent version of Adobe Acrobat Reader before initiating an enrollment action using Internet-based PECOS.
The Internet-based Provider Enrollment, Chain and Ownership System (Internet-based PECOS) can be used in lieu of the Medicare enrollment application (i.e., paper CMS-855) to:
• Submit an initial Medicare enrollment application
• View or change your enrollment information
• Track your enrollment application through the web submission process
• Add or change a reassignment of benefits
• Submit changes to existing Medicare enrollment information
• Reactivate an existing enrollment record
• Withdraw from the Medicare Program
• View or change your enrollment information
• Track your enrollment application through the web submission process
• Add or change a reassignment of benefits
• Submit changes to existing Medicare enrollment information
• Reactivate an existing enrollment record
• Withdraw from the Medicare Program
Advantages of Internet-based PECOS
• Faster than paper-based enrollment (45 day processing time in most cases, vs. 60 days for paper)
• Tailored application process means you only supply information relevant to YOUR application
• Gives you more control over your enrollment information, including reassignments
• Easy to check and update your information for accuracy
• Less staff time and administrative costs to complete and submit enrollment to Medicare
• Tailored application process means you only supply information relevant to YOUR application
• Gives you more control over your enrollment information, including reassignments
• Easy to check and update your information for accuracy
• Less staff time and administrative costs to complete and submit enrollment to Medicare
Using Internet-based PECOS Is Easy!
Before initiating an enrollment action using Internet-based PECOS, you should review the applicable "Basics of Internet-based Provider Enrollment, Chain and Ownership System (PECOS)" Fact Sheet(s) listed in the Downloads and Links section below.
Individual Physicians and Non-Physician Practitioners
Physicians and non-physician practitioners may access Internet-based PECOS by using the User IDs and passwords that they established when they applied on-line to the National Plan and Provider Enumeration System (NPPES) for their National Provider Identifiers (NPIs). If they did not establish User IDs and passwords at that time (for example, they may have submitted paper NPI applications to the NPI Enumerator and had no reason to establish User IDs and passwords), they may do so now by going to the NPPES hyperlink listed below and following the directions on the screens. If they have forgotten their User IDs or passwords, or otherwise need assistance in this regard, they may contact the NPI Enumerator at 1-800-465-3203 or customerservice@npienumerator.com.
1. Log onto Internet-based PECOS with your NPPES User ID and password.
Click on "PECOS" in the "Related Links Outside CMS" section below.
2. Complete, review, and submit an electronic enrollment application.
Internet-based PECOS will walk you through the application process and supply you with a 2-page Certification Statement for each enrollment application you submit.
Click on "PECOS" in the "Related Links Outside CMS" section below.
2. Complete, review, and submit an electronic enrollment application.
Internet-based PECOS will walk you through the application process and supply you with a 2-page Certification Statement for each enrollment application you submit.
3. Mail the original signed Certification Statement from Internet-based PECOS and supporting documents to the Medicare contractor within 7 days of your electronic submission.
The effective date of filing an enrollment application is the date the Medicare contractor receives the signed and dated (blue ink recommended) Certification Statement. Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated
The effective date of filing an enrollment application is the date the Medicare contractor receives the signed and dated (blue ink recommended) Certification Statement. Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated
Certification Statement.
Organizational Providers and Suppliers
Obtaining access to Internet-based PECOS by organizational providers and suppliers (e.g., professional associations, professional corporations, limited liability corporations) involves several steps, and the first step must be taken by the Authorized Official (AO) of the DMEPOS supplier.
2011 CPT updates in interventional cardiology
33620 Application of right and left pulmonary artery bands (eg, hybrid approach stage 1)
33621 Transthoracic insertion of catheter for stent placement with catheter removal and closure (eg, hybrid approach stage 1)
33622 Reconstruction of complex cardiac anomaly (eg, single ventricle or hypoplastic left heart) with palliation of single ventricle with aortic outflow obstruction and aortic arch hypoplasia, creation of cavopulmonary anastomosis, and removal of right and left pulmonary bands (eg, hybrid approach stage 2, Norwood, bidirectional Glenn, pulmonary artery debanding)
37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty
37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)
37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)
37224 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty
37225 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed
37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
37227 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
37228 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty
37229 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed
37230 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
37231 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)
37233 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)
37234 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)
37235 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)
Workflow process in Medical Billing
The following details provides the workflow of Medical billing process.
1. The doctor sees the patient. After seen the patient, Dr front office person send the all information pertaining to the patient which includes Patient Demographics (Face sheet), super bills/charge sheets, insurance verification data and a copy of the insurance card to Indian Billing office via FTP/fax .
2. In Billing office, Scanning department retrieves the files and prints them and ties up with the control log for number of files and pages.
4. Illegible /missing documents are identified and a mail is sent to the Billing office for rescanning.
6. Coding and pre-coding of the super bill/charge sheet and demographics for insurance, doctors, modifiers, CPT and diagnosis are done wherever required.
7. The claims data entry operator creates a charge, according to the billing rules pertaining to the specific carriers and locations .All charges are accomplished within the agreed turnaround time with the client.
8. Charges are verified by audit department for accuracy and compliance with rules.
9. Claims are filed and information sent to the Transmission department.
10. Transmission department prepares a list of claims that go out on paper and through the electronic media. Once claims are transmitted electronically, confirmation reports are obtained from clearing house and filed after verification. Paper claims are printed and attachments done if required and put into envelopes and sent to the US for postage and mailing.
11. Clearing house transmission rejections/errors are analyzed and take corrective action and again transmit the claims to clearing house
12. Once recieve the EOB( Expalnation of Benefits-Payments), Cash applied team receives the cash files and post the payment in the respective accounts. This would helps to reconcile the deposits at the end of each month. while psoting the EOBS, Overpayments are immediately identified and sene the information to Dr office to refund the amount into the respective insurances.
13. All rejected/denied claims, research the reason for denial with remark codes in the EOB’s or Explanation of Benefits received and take appropriate action to resolving the issue.
14. AR analysts are the key to any group. They record the processing time of each insurance companies and identify all claims falling above the processing time. Then the claims are researched for completeness and accuracy and insurance carriers are called if required. AR analysts are responsible for the cash collection and resolving all problems to enable the account to have clean AR.
15. Insurance Calling team, calls to the insurance companies to identify the reasons for non-payment of the claims.Calling details are passed on to the AR Analysts for resolution. Calling team works during the American Time zones.
16. Patient calling team calls up the patients to confirm receipt of bill and when they are going to pay. Based on client’s approvals budget plans and discounts for immediate payments are also undertaken.
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