Medical insurance billing can be one of the most challenging jobs faced in the medical industry. The insurance companies will use whatever excuse they can to prevent having to pay on a claim. That is why a person who does medical insurance billing needs to be properly trained in both the technical and legal aspects of the job. We will look at medical insurance billing as done in a nonhospital setting.
Instructions
1. Obtain the patient encounter form from the provider. This form will tell you exactly what procedure the provider has done. The provider is also responsible for determining the level-of-care will be entered for the visit. Some electronic billing systems will have this information available only on the computer, so you may or may not receive a paper patient encounter form.
2. Log on to the medical billing software provided at your office. Go into the section to establish a claim and enter the CPT (current procedural terminology) code that the provider has specified as the proper level code for the patient's visit. On some medical software systems, the provider will enter the code during the exam, and the information will transfer immediately over to the , so you will not have to manually enter the codes.
3. Enter the ICD-9 (International Classification of Diseases, volume 9) code(s) that apply to each aspect of the visit. For instance, if a provider enters a code 99214 for a visit, you will need to list at least three problems that the provider addressed during this visit in order for it to qualify as a level four visit and to be eligible for payment. Most medical office software will carry this information over from what the provider puts in for the diagnosis.
4. Check the encounter form to see if any additional procedures were done at the visit, such as venipuncture, I & D, etc. Check to make sure these CPT codes are put in the computer. Also, specific and distinct procedure codes must have a specific and distinct ICD-9 code, or an insurance company will not pay for it. For example, you cannot bill a chest X-ray (71020) with a diagnosis of hyperlipidemia (272.2); a valid reason for doing the procedure must be presented, such as shortness of breath (786.05) as the reason for the chest x-ray being done. This should all be found in the provider's notes for the visit, as you must have written proof of a reason for doing something in case you are audited by the insurance company.
5. Send the information to the Medical Billing Clearinghouse for processing. If it is a secondary insurance, print the information onto a CMS-1500 form, attach a copy of the first insurance's payment (EOB) and send it by mail to the proper insurance company.
Tags: code that, encounter form, insurance billing, insurance company, billing software
