Putting it All Together

10


Putting it All Together



Objectives


After completing this chapter, readers should be able to:


image Organize and process claims appropriately.


image Complete insurance claims based on patient demographic information.


image Code ICD-9-CM and CPT codes as applicable for correct placement on a CMS-1500 claim form.


image Assign fees based on a fee schedule.


image Read a remittance advisory and correctly apply payments and adjustments.


KEY TERMS






















































































Term Definition
Actual Charge The amount charged by a practice when providing services.
Adjudicate A term for processing payment of a claim.
Adjudicator Person who reviews a claim to determine payments.
Adjustment The amount corrected on a patient ledger due to an error or the difference in the amount billed by a practice and the amount allowed by the insurance company for payment of a claim.
Adjustment Codes Codes used by insurance companies to explain actions taken on a remittance notice.
Aging Report A report to track claim status of patient accounts and to identify individual accounts requiring additional workup for payments and collections.
Allowed Charge The amount set by the carrier for the reimbursement of services.
Assignment Authorization by a policyholder to allow a third-party payer to pay benefits to a health care provider.
Assignment of Benefits A request that money be paid directly to the physician for services rendered on a given claim. In some instances, accepting assignment may result in adjustments or write-offs.
Beneficiary In the Medicare program, one who is eligible to receive Medicare benefits for medical coverage.
Commercial Payer Private health insurance company or employer-based group insurance plan that pays claims for eligible participants.
Co-payment The amount the insured has to pay toward the amount allowed by the insurance company for services.
Customary Charge The amount representing the charge most frequently used by a physician in a given period of time.
Deductible The dollar amount that must be paid by the patient before insurance will pay a claim based on coverage plans and benefits.
Demographic Information Patient identification information. Contains complete patient name, date of birth, Social Security number, and insurance information.
DOS Date of Service.
EIN National standard Employer Identification Number. An IRS federal tax identification number adopted as the national employer identifier (e.g., 42-1212123).
Encounter Form Document to record information regarding services provided to a patient; used for billing purposes.
EOB Explanation of Benefits. A form accompanying an insurance remittance with a breakdown and explanation of payments for a claim. Also referred to as a remittance advisory.
Fee Schedule An established price set by a medical practice for professional services.
Insurance Adjustment or Write-Off Amount required by an insurance company that must be taken off of a patient’s account based on contract agreement and participation.
Ledger Card A record to track patient charges, payments, adjustments, and balances due.
NPI National Provider Identifier. A number assigned to hospitals, physicians, nursing homes, and other health care providers containing alphanumeric characters plus a check digit (e.g., E3E30KL74-6).
POS Codes Place-of-Service Codes. Codes used on insurance claim forms to specify the location where services were provided. A complete list is found in the introduction section of the professional version of the CPT manual.
Remittance Advisory Statement sent by an insurance company detailing how submitted claims were processed for payment along with payment amounts.
Superbill A multipurpose billing form to track procedure and diagnosis codes during a patient encounter or visit.



Insurance Claim Forms Exercises


For the purpose of these exercises, use the following provided physician information for all the claims:











































Physician: A. Good Surgeon, MD
Phone: (314) 123-4444
Address: Miracle Clinic
  12 Hope and Get Well
  Any Town, Missouri 63010
Social Security Number: 222-22-2222
Tax ID #: 43-00110000
Insurance ID Numbers: Medicare Numbers
TRICARE: 002000134567 Clinic: 00001115
Blue Shield: 0101010101010 NPI: 1115222222222
Hospital Address: Mercy General
  1 Get Well
  Anytown, MO 60600

Please refer to Chapter 7 for additional information on these exercises.


image

Note: The physician information cited first pertains to the first set of patients (ending with Worthington) who do not have ledger cards. The fees on the superbill (pages 287-288) apply to all patients in this chapter.


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FIGURE 10-1 Patient registration form for Pamela Jean Brown.

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FIGURE 10-2 Patient registration form for Mary Sue Gannon.

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FIGURE 10-3 Patient registration form for John J. Johnson.

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FIGURE 10-4 Patient registration form for Tommy Q. Public.

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FIGURE 10-5 Patient registration form for Mary J. Pullins.

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FIGURE 10-6 Patient registration form for Josephine M. Smith.

image
FIGURE 10-7 Patient registration form for Mary Worthington.

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FIGURE 10-8 CMS-1500 form.

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FIGURE 10-9 CMS-1500 form.

image
FIGURE 10-10 CMS-1500 form.

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FIGURE 10-11 CMS-1500 form.

image
FIGURE 10-12 CMS-1500 form.

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FIGURE 10-13 CMS-1500 form.


PATIENT


Pamela Jean Brown (Fig. 10-1)











PATIENT


Pamela Jean Brown


Related posts:

  1. Accounts Receivable
  2. Insurance Claim Forms
  3. Diagnostic Coding: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
  4. Service and Procedural Coding: Current Procedural Terminology (CPT)

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Dec 10, 2016 | Posted by in GENERAL SURGERY | Comments Off on Putting it All Together

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