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
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

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 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)

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. 

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.