medicare · 2020. 2. 19. · physician billing • cms 1500 –the form used to request payment for...
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MedicareFrom the Provider’s Perspective
Physician Billing
2019
DAC Medicare Training A Progressive Process
How does Medicare cover me?
Beneficiary Perspective
How will Medicare pay
me?
Provider Perspective
How do I translate
this?
Research Perspective
The 4 parts of Medicare
Medicare
Part A
Hospital
Part B
Medical
Part C
Advantage Plans
Part D
Prescription Drug
Medicare Medicaid
Commercial Self Pay
Who Are the Players?
ProfessionalsIndividuals and Group Practices
FacilitiesAcute Care Hospitals
Nursing HomesRehab Centers
PsychiatricHospices
AncillaryAmbulance
DMEPharmacies
Claim Forms – 2 TypesFacilities
Ancillary
Professionals
Electronic Transmission – 8371 (institutional)
Paper Form – CMS 1450 (UB 04)Inpatient Services (Part A) AND Hospital
Outpatient (Part B)Facilities
Electronic Transmission – 837P (Professional)
Paper Form - CMS 1500Physician Services (Part B) and most
Ancillary (Part B) Physician
Physician Billing
• CMS 1500– The form used to request payment for services
National scope
• Individual providers and group practices• All payers, including Medicare
– Accept/Pay bills
– Collect encounter data
Claims
Encounters
Source: Craig Dickstein
Physician Billing Claims FilesTwo Sections DAC
Diagnosis
Date of service
Patient Demographics
Provider information
Claim
Portion Procedure/Service provided to beneficiary
Line Dx code that justifies treatment that was provided
Location of where service was provided
Specialty of provider & whether there was an assistant
Line Item
CMS 1500 Form (claim portion)
Health Plan Information
Patient Demographic Information
Diagnosis Codes (claim portion)
Diagnosis CodesUp to 12 now
Idiopathic scoliosis737.30
ICD-9: International Classification of Diseases
Volume 1
Dx Codes
• Tabular List of Diseases and Injuries
• NCHS maintains
• Contains 17 Chapters that classify conditions according to etiology(cause of disease) or by specific anatomical(body) system
Volume 2
Dx Codes
• Alphabetic Index to Diseases
• NCHS maintains
• Index to Diseases and Injuries
Table of Drugs and Chemicals
Alphabetic Index to External Causes of Injury and Poisoning (E Codes)
Volume 3
Procedure Codes
• Tabular List and Alphabetic Index to Procedures
• CMS maintains
• Procedures performed in the hospital
inpatient setting, and the codes are used only by the facility.
• 2 digit main category, up to 2 digit subcategories
• According to WHO: “the standard diagnostic tool for epidemiology, health management and clinical purposes”
• Every health condition can be assigned to a unique category. • Up to six characters long
3 digit main categoryUp to 2 digit subcategories786.5 Chest pain
786.50 Chest pain, unspecified
CMS 1500 – Service Level (Line Item)
Place of Service
Standardized 2 digit11 = Office12 = Home21 = Inpatient22 = Outpatient23 = Emergency Room
CPT/HCPC Codes & ModifiersProcedure Codes
Means emergency
CPTs and HCPCs
CPT Current Procedure Terminology
Maintained by (AMA) American Medical Association3 Categories
Category 2Performance
Measures
Category 3Emerging
Technology
E & M99201-99499
Anesthesia00100-01999; 99100-99150
Radiology70010-79999
Surgery10021-69990
Category IProcedures
Pathology/Lab
80047-89398
Medicine90281-99199; 99500-99607
HCPCSHealthcare Common Procedure
Coding System3 Levels
Level 1Based on CPTs
Numeric
Level 2Non-Physician
(DME/Ambulance)
Alphanumeric
Level 3Local Codes
Discontinued In 2003
CMS 1500 – Service Level (Line Item)
Number of units being billedUsually service units = 1
one office visitone treatment
When not equal to 1multiple visitsunits of diabetic suppliesanesthesia minutesoxygen volume (liters)
When multiple services are performed in a single encounter.Refers to the particular diagnoses for which the procedure was performed.Single digit numeric 1-8
CMS 1500 – Provider Info (Line Item)
The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care.
Qualifier/Taxonomy Codes0B State License Number 1B Blue Shield Provider Number 1G Provider UPIN Number1C Medicare Provider Number G2 Provider Commercial Number1D Medicaid Provider Number LU Location Number1G Provider UPIN Number ZZ Provider Taxonomy 1H CHAMPUS Identification NumberEI Employer’s Identification Number
CMS 1500 – Provider Info (Line Item)
The referring provider, ordering provider, or supervising provider who referred,ordered, or supervised the service(s) or supply(ies) on the claim
Refers to the billing office location and telephone number of the provider or supplier
The name and address of facility where services were rendered, identifies the site Where service(s) were provided.
CMS 1500 – Submitted Charges (Line Item)
The “Total Charge” indicates the total billed amount for allservices entered
The “Amount Paid” refers to thepayment received from the patient or other payers
Generally not used but some payers other than Medicare
Physician Billing Claims FilesTwo Sections DAC
Diagnosis
Date of service
Patient Demographics
Provider information
Claim
Portion Procedure/Service provided to beneficiary
Line Dx code that justifies treatment that was provided
Location of where service was provided
Specialty of provider & whether there was an assistant
Line Item