What is Medicare part A and Part B ?

Medicare Part A

Medicare Hospital Insurance, referred to as Part A, provides coverage for medically-necessary inpatient hospital care, specified skilled nursing care, specified services of a home health agency, and other services.
Medicare imposes cost sharing expenses by requiring deductible and coinsurance amounts that may be paid by the Medicare beneficiary, a supplemental insurance policy, or Medicaid.

Medicare Part B

Medicare Supplemental Medical Insurance, referred to as Part B, provides basic health care coverage for the services provided by doctors, suppliers, therapists, and other health care providers.

Medicare imposes cost sharing expenses by requiring deductible and coinsurance amounts that may be paid by the Medicare beneficiary, a supplemental insurance policy, or Medicaid.

Some Medicare beneficiaries receive services from a Medicare HMO. Medicaid does not reimburse a recipient’s Medicare HMO copayments, except for prescribed drug services.

Medicare Part B Appeals Process

View Medicare  Part B Fee-for-Service Appeals Process




Medicare has a formal appeals process that is relatively easy to initiate but must be managed carefully to ensure that the appeal is optimally prepared and that timely filing deadlines are not missed. Many non-Medicare health insurers follow similar procedures.

There are currently 5 levels of Medicare Part B appeals1:

• Level 1: Re-determination

• Level 2: Reconsideration

• Level 3: Administrative Law Judge (ALJ) Hearing

• Level 4: Departmental Appeals Board (DAB) Hearing

• Level 5: Federal District Court Hearing

Each level of appeal must be completed before you are eligible to advance to the next level. In addition, there are time and dollar thresholds that must be met.

Difference between In-network and Out-of-network

In-network vs. Out-of-network Medical Claim Billing

Many new and growing practices seek out in-network insurance carrier affiliations to help build their patient base, while mature practices might choose in-network participation for security and continuity. On the other hand, providers might choose an out-of-network position to eliminate the hassles of dealing with insurance carriers all together. Regardless of which position you choose, there will be pros and cons. Here, we address key considerations of in- and out-of-network with respect to stability, profitability and patient satisfaction.

In-Network


Many practices choose to become in-network providers because of the stability it offers to medical claim billing and the increased potential patient base. In this type of arrangement all medical billing claims tend to be honored more consistently, and reimbursement rates are clearly defined before services are rendered- eliminating much of the medical claim billing guess work. Becoming an in-network provider also allows practices to tap into the existing carrier patient base and take advantage of indirect advertising through online provider directories and the like. The principle downside with becoming an in-network provider is that the credentialing process can be time consuming.
 
With respect to profitability, in-network agreements typically require pricing concessions for medical claim billing of normal services- reducing the reimbursement rate a practice can expect for services. One of the main arguments in favor of such concessions suggests that, because carriers put a large customer base at your finger tips, practices should be able to offset lower rates with higher volume. While there may be some glimmer of truth to this argument, reduced reimbursements require practices work much harder to reach the same level of profitability- often easier said than done.
 
Overall patient satisfaction may be higher for in-network medical claim billing, depending on your market area and the limitations of plan offerings to enrollees. Generally though, patients are familiar enough with co-pays, deductibles and other responsibilities to the point where they know what to expect. There are typically fewer medical billing surprises for patients when visiting and in-network provider- yielding a higher overall sense of satisfaction. This also eliminates much of the guess work for the patient as most of the work falls on the practice's medical claim billing service and the carrier.
 
Out-of-network
 
The out-of-network option can be less stable, particularly for new and growing practices, as there they do not have a definable patient base available through a carrier affiliation. Receiving out-of-network services can also increase the cost of care to patients who might already be paying several hundred dollars per month for insurance premiums and have only limited coverage for a out of network services. Thus, unless your practice is in a high patient volume area, or renders a niche service that's not typically covered by insurance, out-of-network medical claim billing can be a negative determining factor for prospective patients. In more competitive markets, the out-of-network is an option usually only available to more mature practices with a dedicated patient base and excellent reputation, or can support more in-depth advertising.
 
With respect to profitability, choosing out-of-network medical claim billing is a double edged sword for many providers. On the one hand, there are no concessions necessary in fee schedules so rates can be set as the practice sees fit. On the other hand, carriers will typically reimburse the “usual and customary” rate (at best) with the balance left to the patient. And, carriers are not bound to honor medical billing claims the same way as an in-network provider, thus, consistency can be intermittent. Nonetheless, if you have a conscientious patient base and a high success rate on patient collections, out-of-network medical claim billing can be very profitable.
 
Patient Satisfaction can be harder to attain when practicing out-of-network – as mentioned above – since patients may be required to assume greater cost responsibility. If the practice can tactfully control the associated problems associated with patient collections– delinquent payments, non-payments, etc. – then this may not be an issue. In these instances, shortcomings in patient satisfaction can be mitigated by keeping them fully informed on cost and coverage levels from the outset.
 
Of course practices do have the freedom to choose which position they take, in- or out-of-network medical claim billing. Depending on location, type and service area, the choice can even make or break your business. Also remember that choosing one position or the other is not a total commitment, as some practices might blend their options and elect to become in-network with some insurances, while remaining out of network for others. It really depends on the preferences of the practice manager and owner, and past performance of overall medical claim billing. So, when considering your options, weigh the pros and cons and find the right mix to balance a stable patient base with profitability and high patient satisfaction.
 

Types of HMO

Types of HMOs

HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one form; they can have multiple divisions, each operating under a different model, or blend two or more models together.


In the staff model, physicians are salaried and have offices in HMO buildings. In this case, physicians are direct employees of the HMOs. This model is an example of a closed-panel HMO, meaning that contracted physicians may only see HMO patients.

In the group model, the HMO does not employ the physicians directly, but contracts with a multi-specialty physician group practice. Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model"). Kaiser Permanente is an example of a captive group model HMO rather than a staff model HMO, as is commonly believed. An HMO may also contract with an existing, independent group practice ("independent group model"), which will generally continue to treat non-HMO patients. Group model HMOs are also considered closed-panel, because doctors must be part of the group practice to participate in the HMO - the HMO panel is closed to other physicians in the community.[4]

Physicians may contract with an independent practice association (IPA), which in turn contracts with the HMO. This model is an example of an open-panel HMO, where a physician may maintain their own office and may see non-HMO members.

In the network model, an HMO will contract with any combination of groups, IPAs, and individual physicians. Since 1990, most HMOs run by managed care organizations with other lines of business (such as PPO, POS and indemnity) use the network model.

What is a Medicare HMO?

What is a Medicare HMO?

An HMO (Health Maintenance Organization) is a health plan that is also involved in how your health care is delivered. Managed care refers to health plans coordinating your health care with you and the providers that participate in the health plan. HMOs are the most common type of managed care.



A Medicare HMO is an HMO that has contracted with the federal government under the Medicare Advantage program (formerly called Medicare+ Choice) to provide health benefits to persons eligible for Medicare that choose to enroll in the HMO, instead of receiving their benefits and care through the traditional fee for service Medicare program.

What Is a HMO Insurance Policy?

What Is a HMO Insurance Policy?

HMOs, or health maintenance organizations, are one of many types of health insurances available to help cover health-related expenses.


Identification
A health maintenance organization pays for health care provided by members of a network of doctors and hospitals established by the company.
 
Types

Group HMOs are offered through employers or associations for their employees or members and their families. The employer pays for part of the coverage. Individual HMOs are purchased directly from the provider by one person or a family.

Features

HMOs typically require patients to choose a Primary Care Physician and then visit that doctor for care or to receive a referral for a specialist.

Expenses

In exchange for the coverage provided by an HMO, it is necessary to pay a bi-weekly, monthly or annual premium, with group plans typically having lower premiums that individual plans. HMO insurance usually requires the insured to pay co-pays or fees when visiting a doctor or emergency room.

Benefits

HMO insurance policies usually require members to pay fewer health care expenses on their own than other types of health insurance according to the Insurance Information Institute.

Considerations

In some cases, you may be denied coverage by an HMO due to a pre-existing condition or an illness or condition that you have when you apply for coverage. Group policies sometimes feature open enrollment, which guarantees employees coverage despite their general health.

What is the difference between HMO and PPO

Difference between HMO and PPO

A health maintenance organization (HMO) and a preferred provider organization (PPO) have several differences. However, many of them offer quite similar services. Often the PPO will cost a little more because it provides greater flexibility in choosing doctors and seeing specialists than does the HMO.


With a PPO, one can see any doctor one wishes, or visit any hospital one chooses, usually within a preferred network of providers. Depending upon the terms of coverage, a doctor or hospital outside the preferred provider list will cost more and the PPO will pay a range of 70-80% of expenses. Conversely, an HMO requires one see only doctors or hospitals on their list of providers.

few exceptions exist. A large HMO like Kaiser Permanente may allow one to use hospitals or specialists that perform a service their contracted doctors and facilities don’t provide. Unless the health situation is an emergency, obtaining services like these usually involve approval processes and may require a great deal of paperwork and red tape.


The HMO generally also requires that one choose a primary care physician, who will direct care and refer patients to approved specialists. Generally the HMO will not, without prior approval, cover medical expenses incurred by seeing someone who is not contracted with the HMO. Usually an HMO will have defined coverage for emergency medical care when one travels outside its coverage area.

In contrast to the HMO, the PPO allows one to see any doctor one wishes. One does not have to designate a primary care physician, and one can usually see any specialist without referral. The PPO offers choice and flexibility, but is often more expensive.

Most PPOs have a preferred provider list, much like the HMO provider list. Usually, seeing someone on the list means less expense. In fact, the PPO basically has an HMO component and network built into it.

A person who chooses to stay within the preferred provider list makes co-payments for services. It almost always costs less to obtain service from a preferred provider or “network” physician or facility. As well, a PPO often has two different sets of deductibles. Deductible payments for preferred providers tend to be much lower than for those out of network.

In some areas, out of network services may also cost more than in network services because the PPO determines “reasonable cost” of a physician or hospital’s fees. In other words, they may cover 80% of the reasonable costs, which means if the physician or hospital charges more than “reasonable cost, one can spend much more than 20% or greater of the bill.

Further, the PPO is quite inflexible about changing rules when it comes to using services outside the network. One is welcome to do so, but will pay a higher price, even if the preferred provider list cannot offer a similar service. However, some prefer the flexibility of the PPO to the limited coverage aspects of the HMO.

Frequently, employees are not really given a choice as to what insurance they can get. However, when given a choice, they usually have the choice between either an HMO or a PPO. Depending upon one’s health needs, and income level, the PPO may ultimately be a better choice because it does provide access to a greater number of doctors and facilities. It is wise to ascertain the number of network physicians and facilities offered in PPO plans. Some HMO plans may be better deals when the HMO contracts with more providers than does a PPO.

What is an HMO?

What is an HMO?

Health Maintenance Organization - HMO's are both insurers and health care providers. They accept responsibility for a specific set of health care benefits offered to customers and provide those benefits through a network of physicians and hospitals.


Many people today are using HMO's. According to a New York Times article (Freudenheim, M. "Health Care in the Era of Capitalism," New York Times, April 2, 1996), an estimated 58 million Americans are enrolled in HMO's, and another 81 million are enrolled in other types of managed care. A July 8, 1996 Reuter's article says that more than 4 million Medicare beneficiaries and 12 million Medicaid recipients are in HMO's and other managed-care plans.

What kinds of HMO's are there? Staff model HMO's own and operate physician-staffed health centers that offer a broad range of medical care including laboratory, x-ray, vision, and pharmacy services.


Group practice HMO's contract with medical groups to provide health services to HMO members.

What is Write off

Write Off:

This is an amount that the provider has to remove from his books. There are two types of write off: One is contractual write off and the other one is adjustments. Contractual write off are those wherein the excess of billed amount over the carrier’s allowed amount is written off. The fee schedules of each carrier will be loaded in the billing system. When you are posting the EOBs these fee schedules in the system also called system allowed amount would pop up. The difference between the billed amount and the system allowed amount will be the write off, if the EOB allowed amount is less than the system allowed amount. Otherwise the difference between the billed amount and the EOB allowed amount would be the write off.


Adjustments are amounts such as discounts, professional courtesy and other special items that are identified by the provider as those that need not be collected or collected at a lower rate.

What is deductible

Deductible:
This is an amount that the patient owes the carrier every year apart from the premium. The patient has to pay this amount before insurnace started to pay.

What is Co-insurance

Co-Insurance:

This is a part of the allowed amount, which the carrier has determined that the supplementary insurance or the patient is responsible to pay. This will be mentioned clearly in the EOB and should be billed to the secondary carrier or to the patient.

What is Allowed Amount

Allowed Amount :

This is the amount allowed by the carrier. Not all carriers and in all circumstances allow the entire amount billed. Certain carriers have fee schedules based on which they make payments. These fee schedules determine the allowed amount. A Fee Schedule is a list of reimbursement amount for each procedure. These vary according to various localities. This allowed amount is the maximum that a carrier will pay for a particular procedure.

What is EOB

Explanation of Benefits

Explanation of Benefits or EOB is the detailed statement of the carrier’s determination of the claims processed. The determination can result in a payment or a denial.



The Explanation of Benefits contains the following information:

Name of the payer, Name of the provider, Pay-to address, Name of the patient, Name of the member, his id #, date of service, procedure code, amount billed by the provider, amount allowed by the payer, co-insurance, deductible, amount paid by the payer. The amount paid by the payer is equal to the amount shown by the check.

PRe Certification and PRe Authorization

Pre Certification


A requirement that you obtain the insurance company's approval before a medical service is provided. If you fail to follow the pre-certification procedures the company may reduce or deny claim payment. Please note: getting pre-certification does not guarantee claim payment. Also called Utilization Review.


Prior Authorization
Prior authorization is a requirement that your physician obtain approval from your health plan to prescribe a specific medication for you. Without this prior approval, your health plan may not provide coverage, or pay for, your medication.

Both are similar.

Managed care plans

Managed care plans


Definition: Managed care plans are health-care delivery systems that integrate the financing and delivery of health care. Managed care organizations generally negotiate agreements with providers to offer packaged health care benefits to covered individuals.

Purpose: The purpose for managed care plans is to reduce the cost of health care services by stimulating competition and streamlining administration.



Three basic types of managed care plans exist: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans.

• Participants in HMO plans must first see a primary care provider, who may be a physician or an advanced practice registered nurse (APRN), in order to be referred to a specialist. The Independent Practice Association (IPA) contracts with physicians in private practice to see HMO patients at a prepaid rate per visit as a part of their practice.

• PPOs are more flexible than HMOs. Like HMOs, they negotiate with networks of physicians and hospitals to get discounted rates for plan members. But, unlike HMOs, PPOs allow plan members to seek care from specialists without being referred by a primary care practitioner. These plans use financial incentives to encourage members to seek medical care from providers inside the network.

• POS plans are a blend of the other types of managed care plans. They encourage plan members to seek care from providers inside the network by charging low fees for their services, but they add the option of choosing an out-of-plan provider at any time and for any reason. POS plans carry a high premium, a high deductible, or a higher co-payment for choosing an out-of-plan provider

Definition of Pre-Certification

A health plan's pre-certification (pre-authorization, prior authorization) process usually begins with a nurse employed by the health plan completing an initial review of the patient's clinical information, which is submitted by the practice, to make sure the requested service meets established guidelines. If it does, the nurse authorizes the request and the health plan will cover the service. If the service does not meet the guidelines, the nurse refers the case to the health plan's physician reviewer (usually the medical director or a physician consultant), who decides whether to approve or deny the request based on the information provided to the health plan. The physician reviewer may also "pend" the request and ask the physician for additional information before making a final decision.

The pre-certification process is one of the reasons physicians and patients are so dissatisfied with HMOs, which use this strategy more often than other managed care organizations in an effort to contain costs. The trade-off is that HMO premiums are usually lower than those of other managed care organizations that offer fewer restrictions (e.g., PPOs and POS plans). Although many health plans are finding less punitive ways to cut costs, such as using care coordination, some form of utilization management will always be used because it encourages both patients and physicians to make cost-effective decisions and abide by the plan's rules.

What is Pre-certification

What is pre-certification (pre authorization, prior authorization)?

Pre-Certification is an authorization given by your insurance company after you Initial Evaluation to each patient for a specified number of visits. Pre-Certification is not a guarantee of payment. It also requires to identify the service is medically necessary for outpatient hospital services in connection with medical, dental Procedures.

What is considered a pre-existing condition?

A pre existing condition is a medical condition that existed before you obtained health insurance. In most cases, there is a 9 month waiting period for pre existing medical condition coverage. That means that if a company offers you coverage, they may not provide coverage for that specific pre existing medical condition for 9 - 12 months.


In many cases, if have had coverage in place for at least 18 months with no more than a 63 day gap in coverage, and you are just switching insurance companies, the new company will give you credit for having coverage in place and waive the waiting periods for your conditions. This allows you to switch plans if you need to.

Remember, the idea for insurance is to protect yourself in case something bad happens. You don't buy car insurance to cover the cost of oil changes for your car, you buy it for the really bad things that can happen. The same is true for health insurance. You need to have it in place before something bad happens. You can't buy auto insurance after the accident to cover the cost of the accident. The same is true for health insurance

What is Pre-Authorization

Pre-authorization:

This is a requirement to be adhered to before the patient gets registered for treatment. Also known as pre-certification, this requires notification to the plan of certain planned services and all elective inpatient hospitalizations before they are rendered. Depending on the plan, either the patient or the provider must seek pre-authorization for these services. Certain managed care plans require the patients to go through a contracted physician participating in their network. If the patient gets treated through a physician not part of the network then the managed care plan require the physician to call the plan and notify them of the treatment before hand. Only after their approval can the treatment be proceeded. If the treatment is done without the approval, then the managed care plan will not reimburse the physician for their services nor can the physician bill the patient. This approval is called pre-authorization and a copy of this should be made available in the patient’s file before the treatment is rendered. Another requirement is to obtain a second opinion from an impartial physician regarding medical necessity of the procedure to be performed.


A service is deemed medically necessary when-

• It is appropriate for the diagnosis being reported.
• It is provided in the appropriate location.
• It is not provided for the patient’s or his/ her family’s convenience.
• It is not custodial care. (Custodial care is care that can be provided by people who are not trained medical professionals.)


Once the authorization has been granted, an authorization # would be given. This number should be reported on the claim for the service.

What is Type of Services

What is Types of Service?

In medical billing, a patient's medical record is submitted and followed up on insurance claims. This medical record contains information on any treatments, or procedures done during the visit to a hospital or clinic. A percentage of the visit to the doctor is paid for by the insurance company with the help of medical billing. Medical billing consists of service codes that represent the type of service rendered from a healthcare specialist. Here is a list of common codes.


Type of Service Codes
 
01 -  Medical Care


02 -  Surgery

03 -   Consultation

04 -  Diagnostic X-Ray

05 -  Diagnostic Lan

06 -  Radiation Therapy

07 -  Anesthesia

08 -  Surgical Assistance

09 -  Other Medical

10 -   Blood Charges

11 -   Used DME

12 -   DME Purchase

13 -   ASC Facility

14 -   Renal Supplies in the Home

15 -   Alternate Method Dialysis Equipment

16 -   CRD Equipment

17 -   Pre-Admission Testing

18 -   DME Rental

19 -   Pneumonia Vaccin

20 -   Second Surgical Opinion

21 -   Third Surgical Opinion

99 -    Other (e.g. prescription drugs)

Place of service codes

57 - Non-residential Substance Abuse Treatment Facility - A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.

58-59 - Unassigned - N/A

60 - Mass Immunization Center - A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.

61 - Comprehensive Inpatient Rehabilitation Facility - A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.

62 - Comprehensive Outpatient Rehabilitation Facility - A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.

63-64 - Unassigned - N/A

65 - End-Stage Renal Disease Treatment Facility - A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.

66-70 - Unassigned - N/A

71 - Public Health Clinic - A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.

72 - Rural Health Clinic - A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.

73-80 - Unassigned - N/A

81 - Independent Laboratory - A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.

82-98 - Unassigned - N/A

99 - Other Place of Service - Other place of service not identified above.

List of place of service codes

42 - Ambulance – Air or Water - An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

43-48 - Unassigned - N/A

49 - Independent Clinic - A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. (effective 10/1/03)

50 - Federally Qualified Health Center - A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.

51 - Inpatient Psychiatric Facility - A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

52 - Psychiatric Facility-Partial Hospitalization - A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.

53 - Community Mental Health Center - A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.

54 - Intermediate Care Facility/Mentally Retarded - A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.

55 - Residential Substance Abuse Treatment Facility - A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

56 - Psychiatric/Residential Treatment Center - A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.

Define POS

21- Inpatient Hospital - A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

22 - Outpatient Hospital -A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

23 - Emergency Room – Hospital -A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

24 - Ambulatory Surgical Center -A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.

25 - Birthing Center - A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants.

26 - Military Treatment Facility - A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).

27-30 - Unassigned - N/A

31 - Skilled Nursing Facility - A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

32 - Nursing Facility - A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

33 - Custodial Care Facility - A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.

34 - Hospice - A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.

35-40 - Unassigned - N/A

41 - Ambulance - Land - A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

What is POS

POS - Place Of Service

Place of Service denotes the place where the service was rendered within the facility. For e.g. the patient may be an inpatient or an outpatient or in an emergency room or in an ambulatory surgical center. Certain carriers adopt the Medicare coding for Place of service while certain others have their own coding systems. For e.g. Medicare adopts the following places of service: Inpatient 21, Outpatient 22, Office Visit 11, Emergency Room 23, Ambulatory Surgical Center 24 and so on.



Place of Service Code(s) - 01
Place of Service Name - Pharmacy**    
Place of Service Description - A facility or location where drugs and other medically related   items and services are sold, dispensed, or otherwise provided directly to patients.

02 - Unassigned - N/A

03 - School - A facility whose primary purpose is education.

04 - Homeless Shelter - A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters).

05-Indian Health Service Free-standing Facility- A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization.

06-Indian Health Service/Provider-based Facility- A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.

07 - Tribal 638/Free-standing Facility-A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization.

08- Tribal 638/Provider-based Facility- A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.

09 - Prison/Correctional Facility-A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders.

10- Unassigned

11-Office-Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

12-Home-Location, other than a hospital or other facility, where the patient receives care in a private residence.

13-Assisted Living Facility-Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.

14-Group Home *-A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration).

15-Mobile Unit-A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.

16-Temporary Lodging-A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code.

17-Walk-in Retail Health Clinic-A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services. (This code is available for use immediately with a final effective date of May 1, 2010)

18-19 - Unassigned-N/A

20- Urgent Care Facility- Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

Medical terminology abbreviations list

Carrier A public or private insurance organization under contract with the Federal Government's Health Care Financing Administration to process claims and inquiries from physicians and suppliers of service.


Carrier Advisory Committee (CAC) A formal mechanism for: a) providers in a state to be informed of, and participate in, the development of medical policy in an advisory capacity; b) to discuss and improve administrative policies that are discretionary, and; c) for information exchange between the Medicare carrier, health care professionals and Medicare beneficiaries.

Carriers Responsible for handling Medicare claims for services by physicians, suppliers, and other health care practitioners covered under Part B of the Medicare program.

Case A covered instance of sickness or injury.

Case Management The process by which all health related matters of a case are managed by a physician or nurse or designated components of health care, such as appropriate referral to consultants, specialists, hospitals, ancillary providers and services. Case management is intended to ensure continuity and accessibility of services.

Catastrophic Illness Any unusually expensive or lengthy illness that greatly exceeds an individual's ability to pay.

Categorically Needy Those aged, blind, or disabled individuals or families who meet Medicaid eligibility criteria by qualifying for AFDC, SSI, or an optional State financial supplement.

Certificate of Medical Necessity (CMN) A certificate that documents the medical necessity need of a piece of durable medical equipment, prosthetic and orthotic device or a replacement supply.

Change Request HCFA mechanism used for submitting a request to change, add, or delete functions within the operational Medicare system.

Charges Prices assigned to units of medical service, such as a visit to a physician or a day in a hospital. Charges for services may not be related to the actual costs of providing the services. Further, the methods by which charges are related to costs vary substantially from service to service and institution to institution. Different third-party payers may require use of different methods of determining either charges or costs.

Claim A request for payment for benefits received or services rendered.

Claim Line That portion of a claim form, regardless of submission media, that describes a uniquely identified service, supply, or drug and the units, place, dates, charge, and other information directly related to that service, supply, or drug.

Claims Review The method by which an enrollee's health care service claims are reviewed prior to reimbursement. The purpose is to validate the medical necessity of the provided services and to be sure the cost of the service is not excessive.

Clean Bill/Claim A bill/claim requiring no investigation, development, or correction.

Clinical Laboratory A laboratory where microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, or pathological examinations are performed on materials derived from the human body, to provide information for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition.

Clinical Laboratory Improvement Amendment (CLIA) An amendment which states that all clinical laboratory services that are furnished to Medicare beneficiaries must be performed by a provider who has certification from the CLIA program.

Coinsurance The part of each Medicare approved amount a Medicare beneficiary must pay after they have paid the deductible.

Common Working File (CWF) A query/reply system which determines a beneficiary's deductible and entitlement status.

Community Hospital A non-profit hospital established to serve a specific geographic area.

Comparative Performance Report (CPR) A report to monitor and profile physician's billing patterns within each area or locality and provide comparative data to physicians whose utilization patterns vary significantly from other physicians in the same payment and/or locality.

Competitive Medical Plan An arrangement for prepaid care that is not as restricted as a health maintenance organization is in benefits offered, premium calculation, and the like.

Comprehensive Medical Review (CMR) A group of physicians within a medical group that reviews statistical data to determine which physicians are causing an aberrance within the group.

Concurrent Review Review of a procedure or hospital admission done by a health care professional (usually a nurse) other than the one providing the care.

Conditional Payment Medicare makes payment on third party liability cases so providers and beneficiaries do not have to wait for the case to be settled in the courts for payment. Once the case is settled, Medicare receives reimbursement by the other insurance company.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) This statute contains a provision requiring most employers maintaining group health plans to permit employees, their spouses, and their dependents to elect to continue, on a self-pay basis, group coverage for 18, 24, or 36 months, depending on the qualifying event.

Coordination of Benefits (COB) A process in which insurers cooperate to make sure that they do not, together, pay more than the maximum benefit available from any of them.

Coordination Period Specified period of time when the employer plan is the primary payer to Medicare.

Copayment A specified dollar amount or percentage of the charge identified that is paid by a beneficiary at the time of service to a health care plan, physician, hospital, or other provider of care for covered service provided to the beneficiary.

Cost Sharing The general set of financial arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health care services, or both. Cost sharing can also occur when an insured pays a portion of the monthly premium for heath care insurance.

Cost Shifting Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare.

Co-Surgery A single surgical procedure which requires the skills of two surgeons of different specialties.

Coverage Period The period during which an individual is entitled to benefits, and the period in which, if applicable, premiums are due.

Covered Services Those services and benefits to which the eligible beneficiary is entitled under the Medicare program.

Crossover Claim A claim for which both Titles XVIII (Medicare) and Title XIX (Medicaid) are potentially liable for payment or qualifying medical services.

Current Procedural Terminology (CPT) A system of terminology and coding developed by the American Medical Association that is used for describing, coding and reporting medical services and procedures

Medical terminology abbreviations

Balance Billing The practice of charging full fees in excess of covered amounts, then billing the patient for that portion of the bill that the payor does not cover.


Balance Billing Limit A Medicare regulation that limits the maximum fee that a non-participating physician may charge a Medicare beneficiary to 115% above the Medicare-approved amount. The physician is prohibited from collecting the difference or balance between his/her regular fee and the balance billing limit.

Beneficiary Term used to identify any individual eligible for Medicare benefits.

Benefit Period For an inpatient hospital/skilled nursing facility (SNF), this is a period of time starting on the first day that a beneficiary is admitted to a qualified inpatient hospital and ending when he/she has not been an inpatient in a hospital or SNF for 60 consecutive days. If a beneficiary is in an SNF, it ends when he/she has not received any skilled nursing care for 60 consecutive days. There is no limit to the number of benefit periods a beneficiary may have. The beneficiary must pay the Part A deductible for each benefit period. This is also known as a spell of illness. For a hospice, a benefit period is two 90-day periods plus a 30-day period, or an indefinite extension if necessary.

Bilateral Multiple Surgery Multiple surgeries performed on two alike parts of the body, such as the left and right hand.

Bilateral Surgery Procedures that are performed on both sides of the body during the same operative session or on the same day.

Bill/Claim `Bill' and `claim' are used interchangeably for Part A and institutional Part B services (i.e., those services billed through fiscal intermediaries). `Claim' is used for Part B physician/supplier billed through carriers. A bill/claim is essentially a request for payment for medical services rendered by a Medicare provider. Claims are generally submitted on standard claim forms (UB-92 or HCFA 1500) or in an approved electronic format (National Standard Format, ANSI X.12, etc.)

Biologicals Drugs produced by extraction from plant or animal tissue, rather than chemical synthesis. Examples: gamma globulin (from horse serum); human growth hormone.

Blood Deductible Deductible equal in cost to the first three pints of whole blood (or packed red blood cells) received by a beneficiary in a calendar year.


Blue Cross and Blue Shield Association (BCBSA) A national non-profit corporation which promotes the betterment of public health and security, and obtains wide public acceptance of the principle of voluntary, non-profit prepayment of health services. BCBSA holds all rights to the words and symbols that represent both corporations.

Board Certified Physicians who have successfully taken the examination of a medical specialty board.

Buy-in The process whereby a state Medicaid program pays the monthly premiums for Medicare Part B coverage (SMI) in order to provide its Medicaid recipients who are eligible for Medicare with that coverage. Claims processed for the recipients are called crossover claims.

Glossary of Medicare Terminology

Glossary of Medicare Terminology

Abuse Improper or excessive use of program benefits or services by providers or consumers. Abuse can occur, intentionally or unintentionally, when services are used which are excessive or unnecessary; which are not the appropriate treatment for the patient's condition; when cheaper treatment would be as effective; or when billing or charging does not conform to requirements. It should be distinguished from fraud, in which deliberate deceit is used by providers or consumers to obtain payment for services which were not actually delivered or received, or to claim program eligibility. Abuse is not necessarily either intentional or illegal.

Accounts Receivable An account set up to collect money from a beneficiary or provider when there has been a Medicare overpayment. Any payments received from the beneficiary or provider will be applied to the AR until it is satisfied.


Accredited Hospital A hospital approved by the Joint Commission on Accreditation of Health Organizations (JCAHO).

Acute Care A level of care that can be rendered only in a hospital.

Acute Disease A disease which is characterized by a single episode of fairly short duration from which the patient returns to his normal or previous state and level of activity. Acute diseases are distinguished from chronic diseases.

Ad Hoc Request A request to provide non-production support. This support may be in the form of one time updates to production files or the creation of specific one-time or as needed output reports.

Adjudicated Claims A claim that has been fully processed though the system, has been determined to be payable or denied, and for which notification via and EMOB or a remittance advice indicating payment or denial has been mailed.


Adjudication Determination of payment allowance on a claim.

Adjustment Bill/Claim A correction bill/claim subsequent to an original bill/claim which was incorrectly processed or which was incomplete and could not be processed.

Administrative Law Judge Hearing official assigned to the Office of Medicare Hearings and Appeals. Conducts evidentiary hearings on appeals from Medicare Part A and B determinations.

Admission Entry to a hospital as a patient.

Admitting Physician The physician responsible for admission of a patient to a hospital or other inpatient health facility. Some facilities have all admitting decisions made by a single physician (typically a rotating responsibility) called an admitting physician.

Advance Directives Written documents stating how you want medical decisions made for you if you lose the ability to make decisions for yourself. The two most common advance directives are: Living Wills and Durable Powers of Attorney for Health Care.

Advance Notice When the provider believes that Medicare will not make payment due to a service being "not reasonable and necessary," an advance written notice to the beneficiary can protect the provider from liability.

Affiliated Hospital One which is affiliated in some degree with another health program, usually a medical school

Age Discrimination in Employment Act of 1967 (ADEA) As amended in 1978, ADEA requires employers with 200 or more employees to offer older active employees under age 70 who are eligible for Medicare (and their spouses if they are also under age 70) the same health insurance coverage that is provided to younger employees.

ALJ Hearing The ALJ hearing is a quasi-judicial administrative hearing conducted by a Federal ALJ. It results in a new decision by an independent reviewer.

Allied-Health Personnel Specially trained health workers other than physicians, dentists, podiatrists and nurses. The term has no constant or agreed upon meaning: sometimes meaning all health workers who perform tasks which must otherwise be performed by a physician; and sometimes referring to health workers who do not usually engage in independent practice.

Allowed Amount Either the amount billed for a medical service or the amount determined payable by Medicare, whichever is the lesser figure.

Alternative Delivery Systems (ADS) A method of providing a comprehensive health care program to subscribers other than the traditional fee-for-service method (e.g., HMOs, PPOs).


Ambulatory Care Health services which are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients.

Ambulatory Surgery A large, though limited, range of procedures using operative and anesthesia techniques that allow the patient to recuperate at home, rather than in the hospital, immediately following the operation.

Ambulatory Surgical Center (ASC) a distinct entity which operates exclusively to provide outpatient surgical services.

American Association of Retired Persons A service and lobbying group composed of people age 50 and over that has the Medicare program among its concerns. Commonly known as the AARP.

American Hospital Association (AHA) A voluntary association of hospitals organized for the purpose of helping hospitals provide better patient care.

American Medical Association (AMA) A public service organization dedicated to the advancement of science and medicine and betterment of the public health and welfare.

Americans with Disabilities Act A law enacted in 1990 that prohibits discrimination against persons with disabilities in such areas as public accommodations and terms and conditions of employment.

Amount in Controversy The difference between the amount charged the beneficiary less the amount the Medicare carrier allowed, less any remaining Part B Cash Deductible and/or, if applicable, Part B Blood Deductible, less 20 percent of the remainder. To meet the amount in controversy requirement, a beneficiary or provider may combine any series of claims for Part B services as long as the appeal is timely filed for all claims at issue and the claims are properly at the level of the appeal requested.

Ancillary Charge A charge used on institutional claims for any item except hospital and physician fees, such as drug, lab, or X-ray charges.

Ancillary Services Hospital services other than room and board, and professional services. They may include X-ray, drug, laboratory or other services.

Anesthesiologist or Anesthetist A person who administers anesthetics for surgery and diagnostic procedures. An anesthesiologist is always a holder of the M.D. or D.O. degree; an anesthetist may be a nurse-anesthetist or an anesthesia technician.

Appeal Requests Written statements that convey an explicit or implicit request for review of the initial determination, or a dissatisfaction with the most recent determination.

Approved Charge The amount that Medicare has determined is appropriate for payment to a physician for a service, based on his and his colleagues' histories of charge. See Usual, customary, and reasonable reimbursement system.

Assigned Claim A Part B claim for physician or supplier services where the provider agrees to accept the Medicare allowed charge as payment in full.

Assignment Payment for covered services goes directly to the physician.

Assistant-at-surgery A surgeon who gives aid to and supports a primary surgeon during a surgical procedure.

Attending Physician The physician primarily responsible for the care of a beneficiary with respect to a particular illness or injury. Also a doctor with staff privileges at a hospital who treats patients there. Usually applied to physicians on the staff of a teaching hospital who have a role in teaching and supervising interns and residents.

Audio Response Unit (IVR) The computerized telephone answering service which allows a beneficiary or provider to check claim status using a touch tone telephone.

How to bill CMS 1500 form

Block 12. The patient or authorized representative must sign and date this Block unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with §§3047.7-3047.3. If the patient is physically or mentally unable to sign, a representative specified in §3008 may sign on the patient’s behalf.

Block 13. The signature in this Block authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Block 9 and its subdivisions. The patient or his/her authorized representative signs this Block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

Blocks 14-33 - Provider of Service or Supplier Information

Block 14. Enter the date of current illness, injury, or pregnancy. For chiropractic services, enter the date of the initiation of the course of treatment and enter the X-ray date in Block 19.

Block 15. Leave it blank. Not required by Medicare.

Block 16. Enter dates if patient is employed and unable to work in current occupation. An entry in this field may indicate employment related insurance coverage.

Block 17. Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.


Block17a – Enter the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPI is not available.



Block 17b Form CMS-1500 (08-05) – Enter the NPI of the referring/ordering physician listed in item 17 as soon as it is available.
 
Block 18. Complete this Block when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
 
Block 19. Enter the date, the patient was last seen and the NPI of his/her attending physician when an independent physical or occupational therapist or physician providing routine foot care submits claims.
 
Block 20. Complete this Block when billing for diagnostic tests subject to purchase price limitations. Enter the purchase price under charges if the “yes” block is checked.



Block 21. Enter the patient’s diagnosis/condition. All physician specialties must use an ICD-9-CM code number and code to the highest level of specificity.

Block 22. Leave it blank. Not required by Medicare.

Block 23. Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.

Block 24a. Enter the month, day and year for each procedure, service, or supply.

Block 24b. Enter the appropriate place of service code from the list provided in §2010.3. Identify the location where the Block is used or the service is performed. NOTE: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code.



Block 24c. Medicare providers are not required to complete this Block.

Block 24d. Enter the procedures, services or supplies using the CMS Common Procedure Coding System (HCPCS).


Block 24e. Enter the diagnosis code reference number as shown in Block 21, to relate the date of service and the procedures performed to the primary diagnosis.

Block 24f. Enter the charge for each listed service.

Block 24g. Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, or anesthesia minutes. If only one service is performed, the numeral “1” must be entered.


Block 24h. Leave it blank. Not required by Medicare.

Block 24i. Leave it blank. Not required by Medicare.

Block 24j. Enter the NPI of the performing provider of service/supplier if they are a and member of a group practice.

Block 24k. Enter the first two digits of the NPI in Block 24j. Enter the remaining six digits of the NPI in Block 24k, including the two-digit location identifier.

When several different providers of service or suppliers within a group are billing on the same CMS-1500, show the individual NPI in the corresponding line Block.

Block 25. Enter your provider of service or supplier Federal Tax I.D. (Employer Identification Number) or Social Security Number.

Block 26. Enter the patient’s account number assigned by the provider of service’s or suppliers accounting system. This field is optional to assist you in patient identification. As a service, any account numbers entered here will be returned to you.


Block 27. Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits.

Block 33. Enter the provider of service/supplier’s billing name, address, zip code, and telephone number.


Enter the NPI, including the 2-digit location identifier, for the performing provider of service/supplier who is not a member of a group practice.

CMS 1500 field and descriptions

Block 8. Check the appropriate box for the patient’s marital status and whether employed or a student.



Block 9. Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in Block 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.

 Block 9a. Enter the policy and/or group number of the Medigap insured preceded by Medigap

Block 9b. Enter the Medigap insurer’s birth date and sex.


Block 9c. Leave blank if a Medigap *PAYERID is entered in Block 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and zip code copied from the Medigap insurer’s Medigap identification card.

For example:

1257 Anywhere Street

Baltimore, Maryland 21204

is shown as “1257 anywhere St MD 21204.”

Block 9d. Enter the nine-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.

Block 10a. Check “YES” or “NO” to indicate whether employment, auto liability, or Thru other accident involvement applies to one or more of the services described Block 10c. in Block 24. Enter the state postal code. Any Block checked “YES,” indicates there may be other insurance primary to Medicare. Identify primary insurance information in Block 11.



Block 10d. Use this Block exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient’s Medicaid number preceded by “MCD.”

Block 11. THIS BLOCK MUST BE COMPLETED. BY COMPLETING THIS BLOCK, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.



If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Blocks 11a - 11c.

Block 11a. Enter the insured’s birth date and sex if different from Block 3.


Block 11b. Enter employer’s name, if applicable. If there is a change in the insured’s insurance status, e.g., retired, enter the retirement date preceded by the word “RETIRED.”

Block 11c. Enter the nine-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB.

Block 11d. Leave it blank. Not required by Medicare.

CMS 1500 CLAIM FORM FILING INSTRUCTIONS

CMS 1500 CLAIM FORM FILING INSTRUCTIONS

Block 1-13: - Patient and Insured Information.

Block 1. Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed check the Medicare box.



Block la. Enter the patient’s Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.



Block 2. Enter the patient’s last name, first name, and middle initial, if any, as shown on the patient’s Medicare card.



Block 3. Enter the patient’s birth date and sex.


Block 4. If there is insurance primary to Medicare, either through the patient’s or spouse’s employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. If Medicare is primary, leave blank.


Block 5. Enter the patient’s mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and phone number.


Block 6. Check the appropriate box for patient’s relationship to insured when Block 4 is completed.


Block 7. Enter the insurer’s address and telephone number. When the address is the same as the patient’s, enter the word “SAME.”

Internation classification of procedure

CLASSIFICATION OF ICD-9-CM CODES (DIAGNOSIS)

Dx. Range Description

001-139 Infectious and Parasitic Diseases

140-239 Neoplasm

240-279 Endocrine, Nutritional and Metabolic Diseases, And Immunity Disorders

290-319 Mental Disorder

320-389 Nervous System and Sense Organs

390-459 Diseases of the Circulatory Systems

460-519 Diseases of the Respiratory Systems

520-579 Diseases of the Digestive Systems

580-629 Diseases of the Genitourinary Systems

630-677 Complications of Pregnancy, Childbirth, and the Puerperium

680-709 Diseases of the Skin and Subcutaneous Tissue

710-739 Diseases of the Musculoskeletal System and Connective Tissue

740-759 Congenital Anomalies

760-779 Certain Conditions Originating in the Perinatal Period

780-799 Symptoms, Signs, And III-Defined conditions

800-999 Injury and Poisoning

V01-V85 Supplementary Classification of Factors Influencing Health Status
And contact with Health services

Classification of CPT codes

CPT Range Description
00100-01999 Anesthesia
00021-69990 Surgery-General
10040-19499 Surgery-Integumentary System
20000-29999 Surgery-Musculoskeletal System
30000-32999 Surgery-Respiratory System
33010-37799 Surgery-Cardiovascular System
38100-38999 Surgery-Hemic and Lymphatic System
39000-39599 Surgery-Mediastinum and Diaphragm
40490-49999 Surgery-Digestive system
50010-53899 Surgery-Urinary System
54000-55899 Surgery-Male Genital System
55970-55980 Surgery-Intersex
56405-58999 Surgery-Female Genital System
59000-59899 Surgery-Maternity care and Delivery
60000-60699 Surgery-Endocrine System
61000-64999 Surgery-Nervous System
65091-68899 Surgery-Eye and Ocular Adnexa
69000-69979 Surgery-Auditory System
69990-69990 Surgery-Operating Microscope
70010-79999 Radiology
80048-89356 Pathology and Laboratory
90281-99199 Medicine – Part 1
99500-99602 Medicine – Part 2
99201-99499 Evaluation and Management
A0021-A0999 Transportation Services Including Ambulance
A4206-A7527 Medical and Surgical Supplies
A9150-A9999 Administrative, Miscellaneous & Investigational
E0100-E8002 Durable Medical Equipment
G0008-G9130 Procedures/Professional services
J0120-J8999 Drugs Administered Other than Oral method
J9000-J9999 Chemotherapy Drugs


Evaluation & Management (E&M) codes - 99201 to 99499

9920* (1,2,3,4,5)– OV -New
9921* (1,2,3,4,5)– OV -Established
9922* (1,2,3)– Hospital visit initial
9923* (1,2,3)– Hospital visit follow-up
9924* (1,2,3,4,5)– OV consulting
9925* (1,2,3,4,5)– Hospital visit consulting
99238/239 – Hospital Discharge
9935* (4,5,6,7) – Prolonged service (additional code used with E&M code)
99291/99292 – Critical care

COMMONLY USED CODES:


Office Visit (POS-11)
9920* (1,2,3,4,5) – Office visit New
9921* (1,2,3,4,5) – Office visit Established
9924* (1,2,3,4,5) – Office consultation
9938* (1 to 7) -Physical exam new patient (These codes are not covered by Medicare. We have to use 9* for the claim.)

99381 (under 1 year of age)
99382 (1-4 years of age)
99383 (5-11 years of age)
99384 (12-17 years of age)
99385 (18-39 years of age)
99386 (40-64 years of age)
99387 (65+ years of age)

9939* (1 to 7) - Physical exam established patient
93000 - EKG (Electro Cardiogram)
99000 - Specimen handling
90772 - Injection Admin
90471,90472 - Vaccination Admin
9935* (4,5,6,7)- Prolonged services


Hospital Visit In Patient (POS – 21)

9922* (1,2,3) - Hospital visit initial (admission)
9923* (1,2,3) - Hospital visit follow-up
99238 / 99239 - Hospital discharge
9925* (1,2,3,4,5)- Hospital consultation initial
99291 - Critical care (30-74 Min)
99292 - Critical care (additional 30 Min)
99234-99236 - Admit & Discharge on same day

Hospital Visit Out Patient (POS – 22)

9921* (8,9)/99220-Hospital observation care
99217 - Hospital observation Discharge

Home Visit (POS – 12)

9934* (1,2,3,4,5) - Home Visit Initial
99347 to 99350 - Home visit follow up

Nursing Visits (POS-31, 32,33)

9930* (4,5,6) - Nursing home initial
9930 *(7,8,9,10)- Nursing follow-up
99315/99316 - Nursing home discharge
9932 (4,5,6,7,8) - Rest home new patient
9933 (4,5,6,7) - Rest home follow-up

CPT Terminology

CPT- Current Procedural Terminology
Current Procedural Terminology (CPT) is a listing of descriptive terms and identifying codes for reporting medical services and procedures.

The purpose of CPT is to provide a uniform language that accurately describes medical, surgical and diagnostic services - serving as an effective means for reliable nationwide communication among physicians, patients and third parties.
CPT - Systematic method for coding procedures & services performed by physicians or other healthcare providers.
ICD-9-CM Codes - International Classification of Diseases

ICD-9-CM is an acronym for International Classification of Diseases 9th Revision Clinical Modification.

ICD-9-CM is a statistical classification system, which arranges diseases and injuries into groups according to established criteria.

how to bill CMS1500 - HCFA1500

Instructions in §§2010.1 and 2010.2 (see below) that require the reporting of 8-digit dates
in all date of birth fields (items 3, 9b, and 11a), and either 6-digit or 8-digit dates in all
other date fields (items 11b, 12, 14, 16, 18, 19, 24a, and 31) are effective for providers of
service and suppliers as of 10/01/98.

Providers of service and suppliers have the option of entering either 6 or 8-digit dates in
items 11b, 14, 16, 18, 19, or 24a. However, if a provider of service or supplier chooses
to enter 8-digit dates for items 11b, 14, 16, 18, 19, or 24a, he or she must enter 8-digit
dates for all these fields. For instance, a provider of service or supplier will not be
permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19 and a 6-digit date for item
24a. The same applies to providers of service and suppliers who choose to submit 6-digit
dates too. Items 12 and 31 are exempt from this requirement.

what is the purpose of claim form

The Form HCFA-1500 answers the needs of many health insurers. It is the basic form prescribed by HCFA for the Medicare program for claims from physicians and suppliers, except for ambulance services. It has also been adopted by the Office of Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS) and has received the approval of the American Medical Association (AMA) Council on Medical Services.


Use these instructions for completing this form. The Form HCFA-1500 has space for physicians and suppliers to provide information on other health insurance. Use this information to determine whether the Medicare patient has other coverage which must be billed prior to Medicare payment, or whether there is a Medigap policy under which payments are made to a participating physician or supplier.

What is CMS -1500 or HCFA Claim form-1500

HEALTH INSURANCE CLAIM FORM - HCFA-1500

CMS - 1500 form has 33 Fields. The upper right margin of the claim form should not be used. This area of the claim form is used by the carrier. Any obstructions in this area will hinder timely and accurate processing of claims. The top right margin of the claim form should NOT contain:any type of adhesive-backed labelprinting or headings (including the Medicare carrier address)ink, markers, whiteout, etc.Please print legibly or type all information. Claims may also be computer-prepared.