Current Procedural Terminology-CPT

In this part, we find out about current technique terminology(CPT) codes, what is CPT and how to denote them and what is the utilization of CPT codes.

According to American Medical Association Current Procedural Terminology (CPT) is a medical code set that is utilized to report medical, surgical, and analytic methods and administrations to elements, for example, doctors, medical coverage organizations, and accreditation associations.

Carriage paid to (CPT) is a business term meaning that the vendor conveys the merchandise to a bearer or to someone else designated by the dealer, at a place commonly settled upon by the purchaser and dealer, and that the vendor pays the cargo charges to transport the products to the predetermined goal. Continue reading “Current Procedural Terminology-CPT”

USA healthcare/medical Billing abbreviation part-3

In this chapter, we learn to remain part of abbreviation alphabet N to W. After this chapter we will cover other parts of USA healthcare and Medical Billing/coding.

N

Non-Covered Charge (N/C): N/Cs are procedures and services not covered by a person’s health insurance plan.

Not Elsewhere Classifiable (NEC): A term used to describe a procedure or service that can’t be described within the available code set.

Network Provider: A provider within a health insurance company’s network that has contracted with the company to provide discounted services to a patient covered under the company’s plan.

Non-participation: This is when a provider refuses to accept Medicare payments as a sufficient amount of the services rendered to a patient.

National Provider Identifier (NPI) Number: A unique 10-digit number provided to every healthcare provider in the U.S. as mandated by HIPAA.

O

Office of Inspector General (OIG): The organization responsible for establishing guidelines and investigating fraud and misinformation within the healthcare industry. The OIG is part of the Department of Health and Human Services.

Out-of-Network: Out-of-network refers to providers outside of an established network of providers who contract with an insurance company to offer patients healthcare at a discounted rate. People who go to out-of-network providers typically have to pay more money to receive care.

Outpatient: This term refers to healthcare treatment that doesn’t require an overnight hospital stay, including a routine visit to a primary care doctor or a non-invasive surgery.

P

Patient Responsibility: This refers to the amount a patient owes a provider after an insurance company pays for their portion of the medical expenses.

Primary Care Physician (PCP): The physician who provides the basic healthcare services for a patient and recommends additional care for more serious treatments as necessary.

Point of Service Plans: A plan whereby patients with HMO membership may receive care at non-HMO providers in exchange for a referral and paying a higher deductible.

Place of Service Code: A two-digit code used on claims to explain what type of provider-performed healthcare services on a patient.

Preferred Provider Organization (PPO): A plan similar to an HMO whereby a patient can receive health care from providers within an established network set up by an insurance company.

Practice Management Software: Software used for scheduling, billing, and recordkeeping at a provider’s office.

Preauthorization: Some insurance plans require that a patient receive preauthorization from the insurance company prior to receiving certain medical services to make sure the company will cover expenses associated with those services.

Pre-Certification: A process similar to preauthorization whereby patients must check with insurance companies to see if the desired healthcare treatment or service is deemed medically necessary (and thus covered) by the company.

Pre-determination: A maximum sum as explained in a healthcare plan an insurance company will pay for certain services or treatments.

Pre-existing Condition (PEC): PEC is a medical condition a patient had before receiving coverage from an insurance company. A person might become ineligible for certain healthcare plans depending on the severity and length of their PEC.

Pre-existing Condition Exclusion: The existence of a PEC denies a person certain coverage in some health insurance plans.

Premium: The sum a person pays to an insurance company on a regular (usually monthly or yearly) basis to receive health insurance.

Privacy Rule: Standards for privacy regarding a patient’s medical history and all related events, treatments, and data as outlined by HIPAA.

Provider: A provider is the healthcare facility that administered healthcare to an individual. Physicians, clinics, and hospitals are all considered providers.

Provider Transaction Access Number (PTAN): This refers to a provider’s current legacy provider number with Medicare.

R

Referral: This is when a provider recommends another provider to a patient to receive specialized treatment.

Remittance Advice (R/A): The R/A is also known as the EOB, which is the document attached to a processed claim that explains the information regarding coverage and payments on a claim.

Responsible Party: The person who pays for a patient’s medical expenses, also known as the guarantor.

Revenue Code: A three-digit code used on medical bills that explains the kind of facility in which a patient received treatment.

Relative Value Amount (RVA): The median amount Medicare will repay a provider for certain services and treatments.

S

Scrubbing: A process by which insurance claims are checked for errors before being sent to an insurance company for final processing. Providers scrub claims in an attempt to reduce the number of denied or rejected claims.

Self-Referral: When a patient does their own research to find a provider and acts outside of their primary care physician’s referral.

Self-Pay: Payment made by the patient for healthcare at the time they receive it at a provider’s facilities.

Secondary Insurance Claim: The claim filed with the secondary insurance company after the primary insurance company pays for their portion of healthcare costs.

Secondary Procedure: This is when provider performs another procedure on a patient covered by a CPT code after first performing a different CPT procedure on them.

Security Standard: The security standard serves as the guidelines for policies and practices necessary to reduce security risks within the healthcare system. The security standard policies work in concert with the security guidelines set in place with the passage of HIPAA.

Skilled Nursing Facility: These are facilities for the severely ill or elderly that provide specialized long-term care for recovering patients. Skilled nursing facilities are alternative healthcare establishments to extended hospital stays and may be covered by eligible patients’ insurance policies.

Specialist: A physician or medical assistant with expertise in a specific area of medicine. Oncologists, pediatricians, and neurologists are among the many specialists in the medical field.

Subscriber: The subscriber is the individual covered under a group policy. For instance, an employee of a company with a group health policy would be one of many subscribers on that policy.

Superbill: A document used by healthcare staff and physicians to write down information about a patient receiving care. The superbill can contain demographic information, insurance information, and especially any diagnoses or healthcare plans written by the physician. A medical billing specialist inputs the information on a patient’s superbill into a claim.

Supplemental Insurance: Supplemental insurance can be a secondary policy or another insurance company that covers a patient’s healthcare costs after receiving coverage from their primary insurance. Supplemental insurance policies typically help patients cover expensive deductibles and copays.

T

Treatment Authorization Request (TAR): A unique number the insurance company gives the provider for billing purposes. A provider must receive the insurance company’s TAR number before administering healthcare to a patient covered by the company.

Taxonomy Code: Medical billing specialists utilize this unique codeset for identifying a healthcare provider’s specialty field.

Term Date: The end date for an insurance policy contract, or the date after which a person no longer receives or is no longer eligible for health insurance with company. Term dates are typically determined on a case-by-case basis.

Tertiary Insurance Claim: A claim filed by a provider after they have filed claims for primary and secondary health insurance coverage on behalf of a patient. Tertiary insurance claims often cover the remaining healthcare costs such as deductibles and co-pays left over after the primary and secondary claims have been processed.

Third Party Administrator (TPA): The name for the organization or individual that manages healthcare group benefits, claims, and administrative duties on behalf of a group plan or a company with a group plan.

Tax Identification Number (TIN): A unique number a patient or a company may have to produce for billing purposes in order to receive healthcare from a provider. The TIN is also known as the employment identification number (EIN).

Triple Option Plan (TOP): Also referred to as the cafeteria plan, this plan gives an enrolled individual the options to choose between an HMO, a PPO, or a traditional point of service plan for their health insurance. Some companies offer triple option plans to their employees to accommodate the needs of a diverse staff.

Type of Service (TOS): A field on a claim for describing what kind of healthcare services or procedures a provider administered.

TRICARE: TRICARE is the federal health insurance plan for active service members, retired service members, and their families, in addition to survivors of service members. TRICARE was previously known as CHAMPUS.

U

UB04: A form used by providers for filing claims with insurance companies. The UB04 form has a format similar to that of the CMS 1500 form.

Unbundling: This term refers to the fraudulent practice of ascribing more than one code to a service or procedure on a superbill or claim form when only one is necessary.

Untimely Submission: Claims have a specific timeframe in which they can be sent off to an insurance company for processing. If a provider fails to file a claim with an insurance company in that timeframe, it is marked for untimely submission and will be denied by the company.

Upcoding: Upcoding is the fraudulent practice of ascribing a higher ICD-9 code to a healthcare procedure in an attempt to get more money than necessary from the insurance company or patient.

Unique Physician Identification Number (UPIN): A unique six-digit identification number given to physicians and other healthcare personnel, which has subsequently been replaced by a national provider identifier (NPI) number.

Usual Customary and Reasonable (UCR): The UCR is the amount of money stipulated in a contract that an insurance company agrees to pay for healthcare costs. After passing the UCR a patient is typically responsible for covering their healthcare costs.

Utilization Limit: The limit per year for coverage under certain available healthcare services for Medicare enrollees. Once a patient passes the utilization limit for a service, Medicare may no longer cover them.

Utilization Review (UR): An investigation or audit performed to optimize the number of inpatient and outpatient services a provider performs.

V

V-Codes: A codeset under ICD-9-CM used to organize healthcare services rendered for reasons other than illness or injury.

W

Worker’s Compensation: Worker’s compensation is paid by an employer when an employee becomes ill or injured while performing routine job duties. Most states have laws requiring that companies provide worker’s compensation.

Write-Off: This term refers to the discrepancy between a provider’s fee for healthcare services and the amount that an insurance company is willing to pay for those services that a patient is not responsible for. The write-off amount may be categorized as “not covered” amounts for billing purposes.

USA Healthcare/Medical Billing abbreviations Part-2

The previous chapter we learn about abbreviations from A to D, in this chapter, we continue the abbreviation part from E to M…

E

Electronic Claim:  When a claim sent electronically to an insurance carrier from a provider’s billing software. This format of claim is called electronic claim.

Electronic Funds Transfer(ETF): A method of transferring money electronically from a patient’s bank account to a provider or an insurance carrier or Insurance company account to providers account is called ETF.

Evaluation and Management (E/M): E/M refers to the section of CPT codes most used by healthcare personnel to describe a patient’s medical needs.E/M CPT codes start from 99201 to 99499.

Electronic Medical Records (EMR): EMR is a digitized medical record for a patient managed by a provider onsite.

Enrollee: A person enrolled in health insurance plan and covered by a health insurance plan is called enrollee.

Explanation of Benefits (EOB): A document attached to a processed medical claim wherein the insurance company explains the services they will be paid or denied is called EOB.

Electronic Remittance Advice (ERA): The digital version of EOB, which specifies the details of payments made on a claim either by an insurance company or required by the patient.

ERISA: Stands for the Employee Retirement Income Security Act of 1974. This act established guidelines and requirements for health and life insurance policies including appeals and disclosure of grievances.

F

Fee for Service: This refers to a kind of medical coverage wherein the supplier is paid for each administration they perform. Individuals with charge for-benefit designs commonly can pick whatever doctor’s facilities and doctors they need to get watch over higher deductibles and co-pays.

Fee Schedule: A document that outlines the costs associated with each medical service provided by the provider.

H

Healthcare Financing Administration(HCFA):  The form used to submit the paper claim is called HCFA form or CMS-1500 form.

Healthcare Financing Administration Common Procedure Coding System (HCPCS): HCPCS is a three-tier coding system used to explain services, devices, and diagnoses administered in the healthcare system.

Healthcare Insurance: This is insurance offered to a group or an individual to cover costs associated with medical care and treatment. Those covered by healthcare insurance typically must pay a premium for getting coverage for treatment.

Healthcare Provider: These are the entities that offer healthcare services to patients, including hospitals, physicians, and private clinics, hospices, nursing homes, and other healthcare facilities.

Healthcare Reform Act: The major healthcare legislation passed in 2010 designed to make healthcare accessible and less expensive for more Americans.

Health Insurance Portability and Accountability Act (HIPAA): HIPAA was a law passed in 1996 with an aim to improve the scope of healthcare services and establish regulations for securing healthcare records from fraud waste and abuse.

Health Maintenance Organization (HMO): A sort of medical coverage arrange for that normally confines scope to mind from specialists who work for or contract with the HMO. It for the most part won’t cover out-of-organize mind aside from in a crisis. A HMO may expect you to live or work in its administration zone to be qualified for coverage.HMOs are systems of medicinal services suppliers that offer social insurance intends to individuals for restorative administrations solely in their system.

Hospice: This refers to medical care and treatment for persons who are terminally ill.

I

ICD-9 Codes: ICD-9 codes are an international set of codes that represent diagnoses of patients’ medical conditions as determined by physicians.

ICD-10 Codes: ICD-10 codes are the updated international set of codes based on the preceding ICD-9 codes. ICD-10 codes are estimated to be mandatory in the American healthcare system by October 2014.Started from 10-01-2015.

Indemnity: Indemnity plans allow you to direct your own healthcare and visit almost any doctor or hospital you like. The insurance company then pays a set portion of your total charges. Indemnity plans are also referred to as “fee-for-service” plans.

In-Network: This term refers to a provider’s relationship with a health insurance company. A group of providers may contract with an insurance company to form a network of healthcare professionals that a person can choose from when enrolled in that insurance company’s health plan.

Inpatient: Inpatient care occurs when a person has a stay at a healthcare facility for more than 24 hours or a patient overnight stay in hospital is count as an in-patient.

Independent Practice Association (IPA): The IPA is a professional organization of physicians who have a contract with an HMO.

Intensive Care: Intensive care is the unit of a hospital reserved for patients that need immediate treatment and close monitoring by healthcare professionals for serious illnesses, conditions, and injuries.

M

Medicare Administrative Contractor (MAC): MACs are contracted with the federal government to process Medicare claims. MAC is a private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.

Managed Care Plan: A health insurance plan in which patient only receive coverage if they see providers who operate in the insurance company’s in-network.

Maximum Out of Pocket: The amount a patient is required to pay. After a patient reaches their maximum out of pocket, their healthcare costs should be covered by their plan.

Medical Assistant: An employee in the healthcare system such as a physician’s assistant or a nurse practitioner who perform duties in administration, nursing, and other ancillary care.

Medical Coder: A medical coder is responsible for assigning various medical codes to services and healthcare plans described by a physician on a patient’s superbill.

Medical Billing Specialist: A medical billing specialist is a person who is working on behalf of provider or hospitals using information regarding services and treatments performed by a provider to complete a claim for filing with an insurance company so the provider can be paid.

Medical Necessity: This term refers to health care services or treatments that are medically necessary for the patient as per requirement. This does not include cosmetic or investigative services.

Medical Record Number: A one of a kind number credited to a man’s therapeutic record so it can be separated from other medicinal records. It is just a single for one patient in one healing center.

Medicare Secondary Payer: The insurance agency that covers any residual costs after Medicare has paid for a patient’s scope.

Medical Savings Account (MSA): An MSA is an optional health insurance payments plan whereby a person apportions part of their untaxed earnings to an account reserved for healthcare expenses. A man with a MSA can just contribute a specific measure of their income every year. Any unused subsidizes in a MSA toward the finish of the year will move over to the following.

Medical Transcription: The process of converting dictated or handwritten instructions, observations, and documentation into digital text formats.

Medicare: Medicare is a government insurance program started in 1965 to provide healthcare coverage for persons over 65 and eligible people with disabilities.

Medicare Coinsurance Days: From 61st through 90th days of inpatient treatment, as per the law, patients has to pay for a part of their human services Medicare coinsurance days.

Medicare Donut Hole: This term refers to the discrepancy between the limits of healthcare insurance coverage and the Medicare Part D coverage limits for prescription drugs.  

Medicaid: Medicaid is a joint federal and state assistance program started in 1965 to provide health insurance to lower-income persons. Both state and federal governments fund Medicaid programs, but each state is responsible for running its own version of Medicaid within the minimum requirements established by federal law.

Medigap: Medigap is supplemental medical coverage under Medicaid for qualified people who require help covering co-pays, deductibles, and other huge charges.

Modifier: Modifiers are additions to CPT codes that explain alterations and modifications to an otherwise routine treatment, exam, or service.

to be continued………..

Thanks

Stay with us, keep learning

Best Wishes

All Pictures source-Google

USA Healthcare/Medical Billing abbreviations

In the journey of USA healthcare or medical billing process, we have to know the abbreviations which are commonly used in this sector. This will help everyone to understand the entire process, their language, and the basic things of medical billing.We go as per alphabetical order A to Z.

In this chapter, we cover A to D.

A
Allowed Amount: The sum an insurance company will reimburse to cover a healthcare service or procedure. The patient typically pays the remaining balance if there is any amount left over after the allowed amount has been paid.
American Medical Association (AMA): The AMA is the largest organization of physicians in the America. dedicated to improving the quality of healthcare administered by providers across the country.

Aging: A formal medical billing term that refers to insurance claims that haven’t been paid or balances owed by patients overdue by more than 30 days.

Ancillary Services: Any service administered in a hospital or other healthcare facility other than room and board, including biometrics tests, physical therapy, and physician consultations among other services.

Advance Beneficiary Notice(ABN): A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. … They do not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan.

Appeal: Appeal occurs when a patient or a provider tries to convince an insurance company to pay for healthcare after it has decided not to cover costs for someone on a claim. Medical billing specialists deal with appeals after a claim has been denied or rejected by an insurance company.

Assignment of Benefits (AOB): ABN refers to insurance payments made directly to a provider for medical services received by the patient. If AOB is not signed by patient, claim payment paid to patient directly.

Application Service Provider (ASP): ASP is an advanced system that enables social insurance suppliers to get to quality medicinal charging programming and advances without expecting to buy and keep up it themselves. Suppliers who utilize ASP ordinarily pay a month to month expense to the organization that keeps up the charging programming.

Authorization: This term refers to when a patient’s health insurance plan requires them to get permission from their insurance providers before receiving certain healthcare services. This term used when a patient’s medical coverage design expects them to get consent from their protection suppliers before getting certain medicinal services administrations. A patient might be denied scope in the event that they see a supplier for an administration that required approval without first counseling the insurance agency.

B

Beneficiary: The beneficiary is the person who receives benefits and/or coverage under a healthcare plan.

C

Capitation: A fixed payment that a patient makes to a health insurance company or provider to recoup costs incurred from various healthcare services. A capitation is different from a out of pocket expense.

Civilian Health and Medical Program of Uniform Services (CHAMPUS): CHAMPUS (now known as TRICARE) is the federal health insurance program for active and retired service members, their families, and the survivors of service members.

Charity Care: This type of care is administered at zero cost to patients who cannot afford healthcare services.

Clean Claim: This refers to a medical claim filed with a health insurance company that is free of errors and processed in a timely manner.

Clearinghouse: Clearinghouses are working as a barrier between provider/hospital and insurance company. They stop the claim before submitting to the insurance company if found any appropriateness in claim. The clearinghouse also known as “Scrubber”.

Centers for Medicare and Medicaid Services (CMS): The CMS is the federal entity that manages and administers healthcare coverage through Medicare and Medicaid. CMS coordinates with providers and enrollees to provide healthcare.

HCFA or CMS 1500: The CMS 1500 is a paper medical claim form used for transmitting claims based on coverage by Medicare and Medicaid plans.

COBRA Insurance- Consolidated Omnibus Budget Reconciliation Act: A federal program that allows a person terminated from their employer to retain health insurance they had with that employer for up to 18 months, or 36 months if the former employee is disabled.

Co-Insurance: The percentage of coverage that a patient is responsible for paying after an insurance company pays the portion agreed upon in a health plan. Co-insurance percentages depending on the health plan.

Contractual Adjustment: This refers to a binding agreement between a provider, patient, and insurance company wherein the provider agrees to charges that it will write off on behalf of the patient.

Coordination of Benefits (COB): COB occurs when a patient is covered by more than one insurance plan. In this situation patient decide and update which one is primary insurance and which one secondary or tertiary.

Co-Pay: A patient’s co-pay is the amount that must be paid to a provider before they receive any treatment or services. Co-pays are separate from a deductible, and will vary depending on a person’s insurance plan.

Current Procedural Technology (CPT) Code: CPT codes represent treatments and procedures performed by a physician in a 5-digit format. CPT codes are entered together with ICD-9 codes that explain a patient’s diagnosis. Medical billing specialists will enter CPT codes into claims so insurance companies understand the nature of healthcare a patient received with a provider.

Credentialing: The application process for a provider to coordinate with an insurance company. Once providers have become credentialed with an insurance company, they have the opportunity to work with that company in providing affordable healthcare to patients.

Credit Balance: Refers to the sum shown in the “balance” column of a billing statement that reflects the amount due for services rendered.

Crossover Claim: When claim information is sent from a primary insurance carrier to a secondary insurance carrier electronically it is called crossover.

D

Date of Service (DOS): The date when a provider performed healthcare services and procedures or patient get treatment is called DOS.

Day Sheet: A document that summarizes the services, treatments, payments, and charges that received on a given day.

Deductible: The amount a patient must pay before an insurance carrier starts their healthcare coverage.

Demographics: The patient’s information required for filing a claim, such as age, sex, address, and family information.

Durable Medical Equipment (DME): This refers to medical implements that can be reused such as stretchers, wheelchairs, canes, crutches, and bedpans.

Date of Birth (DOB): The patient date of birth as per documents.

Downcoding: Downcoding occurs when an insurance company finds there is insufficient evidence on a claim to prove that a provider performed coded medical services and so they reduce or remove those codes. Downcoding usually reduces the cost of a claim.

Duplicate Coverage Inquiry (DCI): A request submitted by an insurance carrier to determine if other health coverage available for a patient.

Dx: The abbreviation for diagnosis codes, also known as International classification of disease.

…………to be continued.

The next post we will know the abbreviations from alphabet  E onward so keep learning and stay connected.

Best Wishes

Picture source-Google

 

USA Healthcare or Medical Billing Process

 

                                                                       Medical Billing Process

In this blog, we examine about American Medical charging and social insurance part. We will know how to USA medicinal services process functions, how they deal with all therapeutic charging offices and administrations and what is least necessity of capability for an act as a restorative biller.

The American Medical Association (AMA) is the biggest association of doctors in the U.S. devoted to enhancing the nature of human services directed by suppliers the nation over. The flow procedural innovation (CPT) and International characterization of disease(ICD) code set are kept up and updated by the AMA as per government guidelines.We will talk about later about CPT and ICD quickly.

Therapeutic charging is an installment rehearse inside the United States wellbeing framework. The procedure includes a social insurance supplier submitting, and following up on, claims with health care coverage organizations to get installment for administrations rendered, for example, medicines and investigations.When a patient goes to the supplier there are sure rules and methods took after by patient and provider(Doctor) for getting administrations and reimbursement.This is called therapeutic charging. The aggregate method is comprehended by above picture.

in the event that you plan to seek after a vocation in medicinal charging and coding. For the motivations behind this lesson, we will cover the conclusion to-end procedure of medicinal charging all in all, and not only the duties of the biller and coder.

The essential employment of therapeutic charging experts is to:

See every individual’s obligation regarding installment, as they may contrast from patient to tolerant

Assess and examine protection scope and therapeutic charges, and get ready exact charging shapes

Gather exact installments from protection designs as well as individual patients

These three essential errands require numerous particular duties inside the therapeutic charging process. In this course, we will separate these duties into a progression of steps that starts when a patient timetables an arrangement and finishes when repayment is gathered from the insurance agency and additionally tolerant.

This blog is the presentation of therapeutic charging procedure and RCM and next blog we will realize which shortened forms regularly utilized as a part of USA social insurance division.

All Pictures source-Google