Proceedings

A. Usage of CMS 1500 claim from:

Any non-institutional doctor (provider) or medical supplier can use this claim form for reimbursement from insurance company.

Examples: 

1. CRNA (Certified Registered Nurse Anesthetists)

2. Clinic Nurse Specialists.

3. Nurse Midwives.

4. NP (Nurse Practitioner).

5. PA(Physician Assistants).

6. Ambulance services.

B. Most Commonly used CPT codes: 

1. 99201 to 99203 : New Patient Office Visit.

2. 99211 to 99215 : Established or Existing Patient Office Visit.

3. 99241 to 99245 : Office Consultant.

4. 99281 to 99285 : Emergency Department (ED) Visit.

C. Who is the "Last Payer Resort"?

Medicaid (State Medicaid) is always will be the last payer. It is a Federal State Plan and pays as the last payer.

D. Full form of FMAP in Medical Billing?

Federal Medical Assistance Percentage.

E. Full form of GPCI in Medical Billing?

Geographic Pricing Cost Index.

F. What is Medicare Payment Mode?

RBRVS is Medicare Payment modes. It has 3 Parts: a. Relative Values, b. GPCI and c. Conversion Factor

Medicare Payment Mode

G. Full form of COBRA?

Consolidated Omnibus Budget Reconciliation Act.

H. What is Discounted Fee for Service?

It is a yipe of payment structure that  PPOs (Preferred Physician Organization) use for their contracted providers.

I. What is URO?

FOr a major course of treatment, such as surgery, chemotherapy and radiation for a patient with cancer, many private payers use the services of a Utilization Review Organization (URO)

J. What is Medicare Limiting Charge?

Medicare Limiting Charge is the highest fee that can be charged for a procedure by a nonparticipating provider. They can not charge more than 115% of the participating provider's fee schedule.

K. Which part of Medicare is also called as Supplementary Medical Insurance?

That is Medicare "Part B".

L. What is "Incident to rules"?

Services supervised by the physician but provided by nonphysician practitioner are billed under "incident to reule".

M. What is Modifier?

It is a code that provides that the service or procedure that has been performed has been altered by some specific circumstances but has not changed in its definition or code.

Modifier as the name implies that modify its service procedure of an item. Under certain circumstances for appropriate reimbursement.

It is two digit codes categorized two labels.
1. Label I Modifier: Normally known as CPT modifiers. It consists of two numeric digit and updated annually ny AMA (American Medical Association).
2. Label II Modifiers: Normally known as HCPCS modifier. And consists of two digit. One is alpha and another is alpha numeric. This modifiers are modified by CMS.

N. Black Lung Program: Paid by Government.

O. Worker's Compensation: Paid by by Govt. And Employer.

P. POD (Proof of Delivery):

It is supplier standard and DMEPOS (Durable Medical Equipment Prosthetics, orthotics and Supplies) suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement.

Q. Clearing House:

In medical billing, the company that functions as intermediaries who forward claim information from healthcare provider to insurance payer are known as Clearing House.

Examples: Zirmed, Availity, Emdeon, Realmed, Ingenix, Navinet etc. 

R. Claims Scrubbing:

Clearing House check the claims for errors and verify that it is compatible with payer's software. The claim with no error are called as Clean Claims which will be sent to insurance company. If a claim is found with error, that will send the claim back to provider with a scrubbing report.