PCM MEDICAL BILLING INFORMATION APPLICATION 3/26/93 ======================================================================= NOTE: This APPLICATION contains a sample of medical billing information put together by PC MANAGEMENT for use by users of this bulletin board. It reflects in principle the Medicare billing scheme for Physician HCPCS service data. PC MANAGEMENT is using data of this type in REFERENCE APPLICATIONS of medical billing information for clients. The applications reflect the "Practice Specific" procedures, codes, regulatory comments, modifiers, and other data essential to accurate coding and timely processing of insurance claims. Claims rejections are minimized and claim amounts are accurately maximized. Medical SPECIALTY Billing and Reimbursement services are available on a fee for service, BBS subscription, and/or project charge. NOTE: Contact Patt @ PCM's HEALTHCARE DATA BBS(HealthCare SYSOP) for Specialty information. Voice contact @ (813) 377-6402 is available Monday - Friday from 9a.m. to 5p.m. eastern standard time. (BBS (813)377-3950 | 2400,N,8,1 ) NOTE: Custom Applications for a full range of physician services can be provided to meet your needs in dBase or WordPerfect format; or to match your special needs. NOTE: If you are new to Medical billing, you may find this APPLICATION useful as a tutorial. The APPLICATION is outlined to provide medical billing information in non medical terminology. ******************************************************************************** INTRODUCTION The basic foundation to medical billing consist of: 1.The "PROCEDURE CODE" which defines the medical service rendered. The most commonly used procedure coding is the three level Health Care Procedure Coding System (HCPCS). a.Level I. the American Medical Association numeric CPT codes which describe various physician and laboratory procedures. b.Level II.the Health Care Financing Administration alpha-numeric codes listing non-physician (and a few physician) services, i.e. supplies, durable equipment, ambulance services, etc. c.Level III. the carrier(in Florida, Blue Cross & Blue Shield) alpha-numeric codes which describe services not listed in level I or level II 2.The "DIAGNOSIS CODE" which defines the reason for the service rendered. The most commonly used diagnosis coding system is The U.S. Department of Health and Human Services, International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). 3.The "FEE" establishes the charge for the medical service rendered. The most commonly used source for basis of establishing the fee structure for physician services is the Resource Base Relative Value system (RBRVs)as required by section 6102(a) of the Omnibus Budget Reconciliation Act of 1989 as amended by the Omnibus Budget Reconciliation Act of 1990 with a revised Medical Economic Index(MEI) to reflect year-to-year price changes affecting the cost of providing physicians' services. The RBRVS uses three elements to determine the "value" of a procedure 1. the work involved, 2. the cost of the medical practice as it relates to the procedure,and 3. the cost of mal-practice insurance as it relates to the procedure. These three elements are then adjusted according the geographic area, or cost of living concept. (see example A.) 4.The "INSURANCE FORM"; document used to transmit, by paper or computer the medical billing data to the insurance carrier for reimbursement. The HCFA 1500 form, the most commonly used data form to submit billing information to a the carrier or insurance company for reimbursement to the provider and beneficiary. This format is utilized for the paper claim submission as well as the Electronic Medical Claims (EMC). 5.The "RULES and REGS" with which the payor governs the provider for the purpose of billing and reimbursement. The most commonly used source for establishing the fee structure for physician services is the Resource Base Relative Value system (RBRVs)as required by section 6102(a) of the Omnibus Budget Reconciliation Act of 1989 as amended by the Omnibus Budget Reconciliation Act of 1990 with a revised Medical Economic Index(MEI) to reflect year-to-year price changes affecting the cost of providing physicians' services. The most commonly used source of rules and regs for medical billing are the Code of the Federal Register(CFR) 42 covering Medicare and Medicaid, and the payor carriers' manual. These publications outline utilization, and other regulatory information specific to medical specialty billing procedure and diagnosis coding. APPLICATION For the purpose of brevity, this Application will address the medical billing as it applies to Medicare. Usually Medicare is the most restrictive regarding rules & regs, and the most studied regarding Resource Base Relative Value (RBRV). The RBRV established a set value for each procedure adjusted by the Geographic Practice Cost Index (GPCI) to reflect to value for the procedure by each geographic area. The next step was to use a conversion factor(CF) amount to convert the value to an actual dollar amount. The CF adjusted yearly according the MEI. Although "documentation' is the key to all good medical billing, this APPLICATION will concentrate on the mechanics of billing, assuming the necessary documentation has been established. The first area of established medical billing documentation should be verification of entitlement or coverage of the beneficary of the medical service. Step 1; the procedure code for the service rendered is selected, and Step 2; the diagnosis for the procedure rendered is selected... These two steps are known as "coding". The most common rule regarding coding is that the diagnosis fit (be relative to) the procedure being rendered. Some procedures are limited in the range of diagnoses that are allowed for the procedure. Some procedures are limited in the number of times the service can be rendered by the physician in a given period of time. The rules and regs specific to the Medicare billing are established through the carrier for each locality and the restrictions on the billing of these procedures are listed in the carrier publication. In the state of Florida, the carrier(Blue Cross Blue Shield) publication is the "UPDATE". All providers are subscribers to UPDATE. service. The initial rules and regulations regarding medical billing are established by the Health Care Financing Administration and published in carrier manuals as well as the Code of the Federal Regulations (CF 42). Physician services are divided into two basic categories, (1) Surgical and (2) Nonsurgical. Certain guidelines apply to Surgical procedures as it relates to reimbursement such as: Global Surgery Post-Op Multiple Surgery Bilateral Surgery Multiple Endoscopic Procedures Co-Surgery Dermatological Surgery Site of Service Procedures Medical billing begins with a physician service represented by a procedure code; a specific diagnosis represented by a diagnosis code; and a fee or charge established by the relative value of the procedure codes. This information is submitted in a format (claim) to the insurance or entitlement carrier for reimbursement (payment) to the provider or beneficiary of the medical service. The reimbursement is calculated according to an established set of rules and regulations initially set forth by the Health Care Financing Administration as interpreted by the carrie processing the "claim". This application is just an outline of the medical billing process. Medical billing for reimbursement has become very technical. The medical biller must be cognizant of ever changing rules and regs. This is especially true in this current age of the "health care crisis". [pec/PCM]