Hospital Billing

Hospital Billing Help on the Internet:

I found the information on MB-GUIDE an excellent tutorial source for help understanding and filling out the UB-04 (CMS-1450) Claim Form for hospital billing. If you prefer a step-by-step approach to filling out the form, it can be found here.

You can find an amazing auto-play tutorial on the UB-04(CMS 1450) that I love on Pearson

General Hospital Billing Tips:

• Medicare 72-Hour Rule. When filing Medicare hospital claims, the 72-hour rule applies. The 72-hour rule states that if a patient receives any treatment related to the inpatient admission, such as diagnostic labs, x-rays, medical equipment, and/or any outpatient services within 72 hours of admission to a hospital (3-day payment window), then all such services are bundled with inpatient service claim if these services are related to the admission. It is important to note that the 72-hour rule applies only to Medicare. Other insurance companies do not cover preadmission labs, x-rays, medical equipment, and so on within 24 hours of hospital admission.
• Rules for Coding Inpatient Diagnoses. Coding inpatient and outpatient cases can differ. One important difference is how uncertain diagnoses are coded. For inpatient cases, code all "rule out," "suspected," "likely," "questionable," "possible," or "still to be ruled out" as if it existed. In addition, the following rules should be noted about the principal diagnosis:
• Codes for signs and symptoms of ICD-10CM are not reported as principal diagnosis.
• When two or more conditions meet the definition principal diagnosis, either condition may be sequenced first unless otherwise indicated by the circumstances of admission or the therapy provided.
• When a symptom is followed by a contrasting comparative diagnosis, sequence the symptom code first.

For complete instructions and guidelines to fill out a UB-04 (CMS-1450) Paper or Electronic Claim Form consult the medical hospital manual and the local UB-04 (CMS-1450) manual.

Hospital Billing Life Cycle 

Diagnosis-Related Group (DRG). A diagnosis-related group, also known as a DRG, is a prospective payment structure on which hospital fee reimbursements are based. The DRG groups diseases, possible related diseases and treatment into a code, which then produces a relative weight for reimbursement. Here is a link to a video to help you understand DRGs.
Medicare Severity Diagnosis-Related Group (MS-DRG). To obtain information on MS-DRG, go to the Federal Register's Website each October 1st for updates.

*find more Web resources for hospital billing on the Internet Resources tab.

Works Cited:
Fordney Insurance Handbook for the Medical Office

CMS-1500 Claim Form Examples

These are examples of CMS-1500 Claim Forms that I have filled out. Click on the link to view the Claim:

Medicaid Claim

Medicare Claim

Tricare Claim

If there is a problem viewing any of these claim forms refresh the page.

Disability Income Insurance and Disability Benefits Programs

Internet Resources for Disability Income Insurance and Disability Benefits Programs

• California Disability Insurance - http://www.edd.ca.gov/disability/
• Disability Information - http://www.edd.ca.gov/pdf_pub_ctr/de2501_jacket.pdf
• Disability Forms and Publications - http://www.edd.ca.gov/disability/di_forms_and_publications.htm

California Unemployment Insurance Site from the Employment Development Department.

Facilities Locator and Directory An interactive online site from the Department of Veterans Affairs.

Glossary of Disability, Aging and Long-Term Care Terms From the U.S. Department of Health & Human Services.

Hawaii Temporary Disability Laws Department of Labor & Industrial Relations, Hawaii.

Social Security Administration

Temporary Disability Insurance Information site from the New Jersey Department of Labor and Workforce Development.

Temporary Disability Insurance Information site from the Rhode Island Department of Labor and Training.

U.S. Department of Labor – Office of Workers’ Compensation Programs (OWCP)  Includes Division of Federal Employees Compensation (DFEC), Division of Energy Employees Occupational Illness Compensation (DEEOIC), Division of Longshore and Harbor Workers' Compensation (DLHWC), and Division of Coal Mine Workers' Compensation (DCMWC).

Resources for Injured Workers Includes care provider information and forms. From the State of New York.

WorkersCompensation.com Forms, statutes, news bulletins, and links to all states.

Workers' Compensation

• If a private patient comes to the office with an industrial injury, a separate health record (chart) and financial record (ledger) should be set up for the work-related injury.
• It is preferable not to schedule a patient to see a physician for a workers' compensation follow-up examination and an unrelated complaint during the same appointment time. Separate appointments (back to back, if necessary) should be arranged. This allows for separate dictation without intermixing the required documentation for each chart.
• If the patient comes in with a Medical Service Order (which authorizes the physician to treat the injured employee) from their employer, the form should be photocopied and a copy retained for the physician's files. The original should be attached to the Doctor's First Report of Occupational Injury or Illness.
• Most Workers' Compensation cases involve accidents causing bodily injuries. Here is a Table of terms that describe intensity of pain and frequency of occurrence of symptoms:
  
  
  
  

Helpful Billing Tips:

1. Ask whether the injury occurred within the scope of employment and verify insurance information with the benefits coordinator for the employer. This will promote filing initial claims with the correct insurance carrier.
2. Either ask the employer the name of the claims adjuster or request that the patient obtain the claim number of his or her case when he or she comes in for the initial visit.
3. Ask the workers' compensation carrier who is going to review the claim. Sometimes independent third-party billing vendors work for the insurance carriers. Get the name and contact information.
4. Educate the patient with regard to the medical practice's billing policies for workers' compensation cases by having him or her complete a patient agreement form.
5. Verify whether prior authorization is necessary before a surgical procedure is performed.
6. Document in a telephone log or patient's record all data for authorization of examination, diagnostic studies, or surgery (for example: date, name of individual who authorizes, response).
7. Obtain the workers' compensation fee schedule for the relevant state.
8. Use appropriate five-digit code numbers and modifiers to ensure prompt and accurate payment for services rendered.
9. Include a diagnostic E code as secondary to the primary diagnosis to report the cause of the injury.
10. Complete the Doctor's First Report of Occupational Injury or Illness form for the relevant state. Submit it within the time frame (California: immediately - 5 days). Some states (including California) allow a late fee if payment is not received within 30 to 45 days.
11. Ask whether there is a state-specific insurance form or if the CMS-1500 (02/12) form is acceptable.
12. Ask what year CPT and Coding Manuals the insurance carrier uses.
13. Submit a monthly itemized statement or bill on the termination of treatment for ND claims.
14. Clearly define any charges in excess of the fee schedule. Attach any x-ray reports, operative reports, discharge summaries, pathology reports, and so on to clarify such excess charges or when by report (BR) is shown for a code selected from the workers' compensation procedure code book.
15. Itemize in detail and send invoices for drugs and dressings furnished by the physician. Bill medical supplies on separate claim or statement, and do not bill with services because this may be routed to a different claims processing department.
16. Call the insurance carrier and talk with the claims examiner (also known as the claims adjuster or claims representative) who is familiar with the patient's case if there is a question about the fee.
17. Search the Internet for a website or write to the workers' compensation state plan office in each state for booklets, bulletins, forms, and legislation information.
18. Find out if the insurance cattier uses "usual and customary" payments tied to the physician's zip code. Most carriers use fee schedules.
19. Follow up and track the date the claim was filed. If no payment has been received or payment has been received beyond the 30- to 45-day deadline, determine whether it meets eligibility requirements for interest.

Delinquent or Slow Pay Claims Procedure:

1. Telephone the patient's employer. Note the name of the person with whim you spoke; the name, address, and telephone number of the workers' compensation carrier, and the claim number. Verify the employer's address.
2. Send a copy of the claim form and an itemized copy of the financial account statement to the carrier. Send a letter and include details of the accident if necessary. For problem claims it may be wise to obtain and complete a Certificate of Mailing form from the US Postal Service.
3. Telephone the insurance cattier after 45 working days, and request the expected date of payment.
4. Be reminded of that payment date by using a computer-automated reminder or a note on the desk calendar. If payment is not received on or before that day, call the carrier again, and ask for payment on a day determined by the facility's expectations.
5. Telephone the patient's employer and explain that there is a difficulty with the carrier. Ask the employer to contact the carrier and have the carrier send payment immediately. You might talk to the patient and suggest that he or she discuss the problem with his or her employer to see if doing so will bring positive action.
6. Send the employer a copy of the financial account statement showing the outstanding balance. If the carrier is not paying, ask the employer for payment. An employer's legal obligation may vary form case to case.
7. Contact the patient only if given information by the carrier or employer that the injury is not work related.
8. Develop office policies that address when an outstanding account should be reviewed (perhaps after 90 or 120 days), whether to continue collection efforts internally, and at which point the account should be turned over to a collection agency.

*find links to Worker's Compensation resources on The Internet Resource tab.

YouTube and the CMS 1500 Form (version 02/12)

• CMS 1500 Form (version 02/12): What You Need to Know - http://www.youtube.com/watch?v=WEGOLNJ6ieE
• New CMS-1500 Form (02/12) - http://www.youtube.com/watch?v=0-AWnjv3uTU

For the link to Jo Moore's video on the CMS 1500 see post YouTube on Medicare