Program Billing Visual Basic
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If youll recall, after examining the patient and performing a pathology test, the doctor diagnosed the patient with streptococcal pneumoniae and prescribed a two week regimen of antibiotics. From that medical report we got these codes. Procedure codes 9. F, new patient visit of low complexity, with the prescription or dispensation of antibiotics. O titer PathologyDiagnosis code 4. The coder would also pass us all of the relevant information for the claim in the superbill, and wed then enter that into a medical claim. Were going to be working with a simplified version of the CMS 1. Course. The CMS 1. Elements 1 through 2. ID number, DOB, address, insurance policy number, and other vital information. These elements also include fields that indicate whether the patient is the subscriber the person paying for insurance or is merely covered by that insurance as in the case of children on their parents insurance. For the most part, these fields are self explanatory, and the information you need to fill them in will be provided by the superbill. For the sake of brevity, well move right to the most important section of the claim. Once we get to Element 2. Billers enter the diagnosis codes into Element 2. The next relevant Element is Element 2. Element 2. 4 is divided into six horizontal rows. In these rows, you enter the date of the procedure, the procedure code, and you re enter in the procedures codes and re enter the diagnosis codes from Element 2. Remember, diagnosis codes on claims are used to demonstrate medical necessity. Box Plot Maker Program. Element 2. 4 is where we put the what the procedure and the why the diagnosis of the medical service. Element 2. 4 also includes a column where the biller can list the charges for each procedure. Were going to get to a visual representation of Element 2. Elements. Element 2. ID. Element 2. 6 is the patients account number with the provider. Well skip to Element 2. Grumpy Loader. Element 2. 9 includes the amount paid by the health insurance. This is the amount the biller is asking the payer to pay, not the amount the payer has already paid. Element 3. 0 is the balance due for the procedure, which is arrived at by subtracting the amount paid Element 2. Element 2. 8. The Balance is the amount that will be passed on to the patient. Elements 3. 1 and 3. NPI. The final Element, Element 3. Lets take a look at a simplified table of Element 2. Well use our first example to enter in the codes. Note that were actually leaving off a few columns to the left of Column F. For the sake of this simplicity, we wont be getting into the information there. Youll see that we attach the diagnosis codes to both of the procedures we enter. Thats because we need to justify the medical necessity for both procedures. Before we get into more detail about this example, well have to discuss charges. Private practices may set the cost of their procedures, but they should align closely to the Medicare costs of a procedure. The Medicare cost of a procedure is determined by evaluating the Relative Value Units RVU of the procedure. These RVUs depend on the amount of time the procedure takes the Work RVU, the cost of that time called the Practice RVU and the likelihood of complications for that procedure the Malpractice RVU. These are each multiplied by a geographic practice cost index and added up. These in turn are multiplied by a conversion factor, which is the dollar amount per RVU. So, for the sake of this example, lets say the cost of the E M procedure is 2. The cost of the Pathology procedure is 3. Wed put each of those in Column F next to their respective procedure. That brings the total cost of the procedure to a nice round 5. Thats what wed put in Element 2. Lets look at those Elements now. How much the payer pays depends on the subscribers insurance agreement. For this first example, lets say the our patient with pneumonia has a basic indemnity agreement, for which he owes a 2. After hes paid that amount, his insurance will cover the rest of the procedure. The deductible and the co pay have already been assigned to the patient, so the first 2. Instead, the amount paid by the pay will be listed as 2. Lets look at Elements 2. That, in a very simplified way, is what a medical claim looks like. This gets sent to the payer and, if its approved, gets sent back to the biller for their records. Lets look at our second example, and throw in a few new elements. Example 2. Our second patient is the 6. If youll recall, this example involved a lot more codes, because it was a much more complicated set of procedures. The codes we came up with in the last example wereProcedure 9. Kitchen Cabinet Installation Cost. Emergency department visit for a condition that requires urgent evaluation by the physician but does not pose an immediate significant threat to life or physiological function7. P3, Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy not otherwise specified patient with severe systemic disease. Diagnosis 5. 40. Acute appendicitis without mention of peritonitis. Now that weve reviewed the codes, lets just right into entering the information in the proper elements. So now weve got the bulk of the claim filled in, but were missing the amount and balance due. Bear in mind also that were just throwing out numbers in Column F. Those are not meant to accurately represent the cost of the procedures in this example. In order to determine the amount and balance due, we have to know what kind of coverage our patient has. Our patient is 6. Medicare. And, sure enough, shes on traditional Medicare, which covers hospital services like the procedure above. Lets say she has 4. Wed take that out right away, so the amount left to cover is 1,4. Medicare Part A can work as a co insurance. For our example, lets say the patient has a 8. That means Medicare owes 8. So we take 8. 0 percent of the 1. Element 2. 9. That makes the balance for the procedure i. Lets look at the completed Elements. And there you have our second claim, or at least the parts of it that are most relevant to the reimbursement process. As you can see, the billing process requires a working knowledge of what codes are and how they work, in addition to proficiency in the monetary side of healthcare. Youll need to know what codes are, how they work, but youll also need to know how much procedures cost, and how to tailor each claim to a specific patients insurance agreement. Video Try Medical Billing This video will break down a medical claim piece by piece, and show you how to correctly enter codes, procedure costs, and patient balances into them.