CERTIFICATION COURSE FOR THE MEDICAL BILLER

Transcription

1 CERTIFICATION COURSE FOR THE MEDICAL BILLER Physician Billing Medical Billing Course.com COPYRIGHT 2015, NAHAEC, LLC ALL RIGHTS RESERVED

2 Chapter 1 Introduction to Medical Billing "Medical billing is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government sponsored programs. Medical billers are encouraged, but not required by law, to become certified by taking a Certification Course such as the course provided by NAHAEC in which the student earns their CMBP designation upon completion. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field." Key Words and Acronyms CMS CMS 1500 Form CPT Encounter Document Group / Group # Guarantor HCFA HMO Individual Insurance Policy Medicare Part A Medicare Part B Medicare Subscriber Number POS PPO Self Pay Superbill TPA 1 P age

3 Table of Contents Key Words and Acronyms... 1 Icon Key... 4 Introduction to Medical Billing... 5 About Medical Billing... 5 Certification Requirements for a Medical Biller... 5 Medical Billing vs Medical Coding... 6 What Does an Employer Look for in a Medical Biller?... 8 Applying for a Medical Billing Position... 8 The Medical Billing Meat & Potatoes (Basics)... 9 The Medical Billing Position Duties... 9 Gathering Data Type of Health Insurance Coverage Group Health / Medical Insurance Individual Insurance Policy Medicare Medicaid Personal Injury/Medical Payments Coverage (auto) Worker s Compensation Tricare Managed Care Plans (HMO, PPO, POS) Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Point of Service (POS) Plans Claims Processing What is a CMS 1500 Form (formerly HCFA 1500 Form)? Breaking Down the CMS 1500 Form Filing Claims Claim Acknowledgement Receiving Payment Generating Reports CHAPTER 1 STUDY GUIDE Sample Superbill / Encounter Document Page

4 Sample Completed CMS 1500 Form Chapter 1 Examination What s Coming in Chapter Motivation A Word from the Developer My Personal History in Medical Billing P age

5 Icon Key Throughout the chapter you will be alerted to pay special attention to certain areas which include Valuable Information, Internet Resources and Platform Opinions. These will be marked with the following icons. VALUABLE INFORMATION *INTERNET RESOURCES PLATFORM OPINIONS CHILL! *The Online / PDF version of this book will contain clickable links to Internet Resource websites. 4 P age

6 Introduction to Medical Billing In this chapter you will learn the basics of medical billing. Whether you plan on working within a physician s office or a hospital or if it is your desire to begin a medical billing business, the basics will be the same. About Medical Billing Before we dive into the basics, let s discuss the Medical Billing Position and understand some important aspects about it. If, perhaps, you have been somewhat intimidated by the position and what it involves, providing you with some factual information will allow you to start fresh with an open mind. Certification Requirements for a Medical Biller There are no certification requirements to become a Medical Biller. In our opening quote, it stated: Medical billers are encouraged, but not required by law, to become certified by taking a Certification Course such as the course provided by NAHAEC in which the student earns their CMBP designation upon completion. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field." Unfortunately, there are associations and individuals who stand to make a profit by leading you to believe that certification is required. Some of them many not come right out and tell you it is not required, but they also certainly do not tell you that it is not. Anyone claiming they provide a National or State Exam is not telling you the truth. 5 P age

7 Medical Billing vs Medical Coding These are 2 entirely separate fields. A Medical Biller is not usually a Medical Coder is not usually a Medical Biller. The online schools who lump these 2 fields together in a Medical Billing & Coding Course are known as Diploma Mills. "A diploma mill (also known as a degree mill) is an unaccredited higher education institution that offers illegitimate academic degrees and diplomas for a fee. These degrees may claim to give credit for relevant life experience, but should not be confused with legitimate prior learning assessment programs. They may also claim to evaluate work history or require submission of a thesis or dissertation for evaluation to give an appearance of authenticity. Diploma mills are frequently supported by accreditation mills, set up for the purpose of providing an appearance of authenticity. The term may also be used pejoratively to describe an accredited institution with low academic admission standards and a low job placement rate. An individual may or may not be aware that the degree they have obtained is not wholly legitimate. In either case, legal issues can arise if the qualification is used in resumés." Source: Diploma mill - A Diploma Mill usually provides instruction (I use that term loosely) in just about everything under the sun, including but not limited to: Dog Grooming Real Estate Investing Tarot Card Reading Astrology Plumbing Medical Billing & Coding 6 P age

8 A Medical Coder is responsible for taking doctor s long hand notes and turning them into digits. A Medical Coder is also responsible for evaluating the CPT and ICD codes being used by a facility in order to assure they are the most accurate and up-to-date. "A clinical coder also known as clinical coding officer, diagnostic coder, medical coder or medical records technician is a health care professional whose main duties are to analyze clinical statements and assign standard codes using a classification system." Source: Clinical coder Medical/Clinical Coders are required, by the state to be certified. Their course of study includes anatomy, biology, physiology and terminology. - A Medical Coding Course can take up to 2 years to complete. - Medical Coding does not provide a Home-Based or Business Opportunity scenario. Medical Billing does. - A Medical Biller deals with finances, submitting claims, accounts receivable. 7 P age

9 What Does an Employer Look for in a Medical Biller? This really depends on the employer. If you have surfed the internet, you may have a preconceived notion that the employer will require 2 years of working experience from a medical billing position applicant. This simply isn t the case. We (NAHAEC) have an expansive network of doctor s offices who prefer to hire persons who have received their training and certification from us --- who have absolutely no prior experience working in the field. The reason is the same reason why, in my medical billing business, I stopped hiring individuals with experience in the field: As a medical billing business owner, hiring staff for the first time, I initially set out to find those persons who had previous experience working within a physician s office. I found that those with experience came with preconceived notions about how the job should be performed, which made it difficult for me to train them to do the job the way I wanted it done. I soon realized that it would be easier and much more beneficial for me to train someone without bad habits and a let s cut every corner attitude. I began to hire only those without experience. I designed an aptitude test that I used for hiring purposes. This worked out nicely. Applying for a Medical Billing Position Look on Craigslist, Indeed.com and other internet resources which list jobs in your area. Submit your professional and appealing looking resume along with a copy of your certification from our course! Also, visit local doctor s offices and hospitals and drop off your resume and your certification. They usually keep these on file for when they are in need of a medical biller. 8 P age

10 The Medical Billing Meat & Potatoes (Basics) Chapter 1 is an Overview of the Medical Billing Process. In any position there exists a process or protocol to follow. In Chapter 1 we are going to touch on these processes without going too much into detail. The idea here is to have you understand the process without overwhelming you with detail. Detail will come in future chapters once you have grasped the basics. In other words, we will hold off overwhelming you until later! Take your time and have fun with this section. If there is something you do not understand, write it down and then go visit the 24/7 Knowledge Base Forum later. You will find a link to the forum in the Student Area. Here we go The Medical Billing Position Duties How these are carried out office-to-office will vary, but the goal is the same. The Medical Biller usually carries out a mix of the following: The Gathering of Patient/Guarantor Demographic Data The Gathering of Patient Billing Data Verification of Insurance Benefits Entering Data into a Practice Management/Medical Billing Software Program Submitting Electronic (EDI) Claims Printing Paper Claim Forms Posting Payments from Insurance Carriers and Patients Check up on Unpaid/ Incorrectly Paid Claims Filing Appeals to Insurance Carriers Printing Patient Statements Soft Collections on Patient Accounts Generating Reports 9 P age

11 Gathering Data Gathering data from a patient is performed so that the physician s office has access to this detail in the patient s file and in the Medical Billing/Practice Management Software System. In order to file insurance claims, you must be able to complete a CMS 1500 Form (formerly known as a HCFA 1500 form). The following are the basics of what is needed per patient in order to complete a CMS 1500 Form: 1. Patient Information 2. Guarantor Information (person responsible for payment) 3. Insurance/Payment Information 4. Procedure Information (CPT/Procedure Codes) 5. Diagnosis Information (ICD-9 or ICD-10-CM/Diagnosis Codes) 1 & 2. Patient & Guarantor Information Surely you have made a trip to the doctor s office. The office gathered your demographic, guarantor and other data either prior to or upon your initial visit. Simply put, this is information about you, your illness/injury and how you are going to pay. The form used to gather this information has several names, but is most commonly known as the Patient Information Form. 10 P age

12 Sample Patient Information Form: The Patient Information Form usually contains the following information: Patient Full Name Address, City, State, Zip Phone Number Date of Birth Social Security Number 11 P age

13 Gender Marital Status Relationship to Insured Employment Information Insurance Information Injury/Illness Information Brief History Emergency Contact information Guarantor Full Name Address, City, State, Zip Phone Number Date of Birth Social Security Number Employment Information Insurance Information 12 P age

14 3. Insurance / Payment Information How will payment be made? Will the patient be using insurance benefits or will they be Self-Pay? The following is a list of the most common types of insurance benefits coverage: Group Health / Medical Insurance Individual Insurance Policy Medicare Medicaid Personal Injury / Medical Payments Coverage (auto) Workers Compensation (work related injury or illness) Tricare (military benefits) Managed Care Plans o HMO (Health Maintenance Organization) o PPO (Preferred Provider Organization) o POS (Point of Service) We will break down these types of coverage in the next section. 13 P age

15 4. Procedure Information Very simply, this is any procedure performed on the patient at the time of visit. The procedure is represented by a CPT Code. (CPT Current Procedural Terminology) Procedure = What Was Done? For your convenience, CPT (current year) can be ordered in the Student Area on the Medical Billing Course website. When a patient visits the doctor, the procedures performed by the doctor are converted to codes. These codes are called CPT codes and are published and maintained by the American Medical Association. Typically, a doctor s office will use a form called a Superbill or Encounter Document (visual page 33) to record the procedures performed on the patient. The CPT codes are reported on the CMS 1500 Form to the insurance carrier for payment. 14 P age

16 Internet Resource American Medical Association (AMA) 5. Diagnosis Information This is the injury / illness / ailment of the patient. This is the reason why a procedure was performed. The diagnosis is represented by an ICD- 9 or ICD-10 code. (ICD International Classification of Diseases) Diagnosis = Why Was a Procedure Performed? For your convenience, ICD10- CM can be ordered in the Student Area on the Medical Billing Course website. Each procedure performed by the doctor must be associated with a diagnosis. The procedure performed is the what was done while the diagnosis code is the why it was done. 15 P age

17 Example: Think about the last time you visited your doctor. Let s say you suffered a cut which required a suture: What was done: Suture Reported by CPT (procedure) Why it was done: Cut - Reported by ICD (diagnosis) Internet Resource Wikipedia List of ICD9 Codes HCPro Just Coding ICD 9 to ICD 10 Conversion Calculator History of ICD-9 and ICD-10 ICD-9 stands for International Classification of Diseases, 9 th Revision and is published by the World Health Organization Headquarters in Geneva, Switzerland. ICD-9-CM stands for International Classification of Diseases, 9 th Revision, Clinical Modification and is adapted from ICD-9 for use in the United States. 16 P age

18 There are several ways for a doctor to report the diagnosis, but for billing purposes the diagnosis is usually recorded on a diagnosis sheet or written in on the Superbill/Encounter Document for each given patient visit. Since 1979, the 9 th Revision has been in effect. You will utilize the 9 th Revision until the 10 th Revision, which will carry a new name; ICD-10-CM The International Statistical Classification of Diseases and Related Health Problems is mandated for usage. The launch date for ICD-10 is October 1, This has been a long-time coming and was actually initially expected to be rolled out as early as The International Classification of Diseases, Tenth Edition (ICD-10) is a clinical cataloging system that goes into effect for the U.S. healthcare industry on Oct. 1, 2015, after a series of lengthy delays. Accounting for modern advances in clinical treatment and medical devices, ICD-10 codes offer many more classification options compared to those found in predecessor ICD-9. For example, if a patient breaks a wrist, ICD-9 does not specify whether it is the left or right wrist, while ICD-10 offers either option. ICD-10 also presents additional details on when a patient is seen by a caregiver and how an injury or disease is progressing or healing. ICD-9's codes are based on three to five letters and numbers, while ICD-10's are based on three to seven letters and numbers. The U.S. has used ICD-9 since In the passing 35-plus years, supporters of ICD-10 say its predecessor has become obsolete, does not account for modern healthcare practices, and lacks ICD-10's specificity for clinical diagnoses and medical device coding. Ironically, ICD-10 itself is 25 years old, having first been adopted by WHO in Some countries began using ICD-10 codes in This completes the 5 basic areas of information needed for completing a CMS 1500 Form. 17 P age

19 Notes: It s Time to Chill! Every once in a while it is just necessary to sit back and reflect on what we have just learned, applying a bit of good, old-fashioned common sense. What seems like a lot of information so far is nothing more than Patient, Procedure and Diagnosis information. No need to get overwhelmed. Remember, Chapter 1 is an overview. If you are new to medical billing, you might be worried about learning everything there is to know about what we have mentioned so far. There is no need. We will break down everything for you in future chapters. For those of you who are not new to medical billing, you just may be bored to death at this point. 18 P age

20 Type of Health Insurance Coverage As listed on Page 11 Group Health / Medical Insurance This type of coverage comes from employment. Normally if you have this type of coverage, you will be provided with a Group Health Insurance Card. The Group is your employer. On the card, the Group is usually identified by its own name and a Group Number. Name and social security number identifies the insured party. Here is what the front of the card may look like: Are you or is someone in your family covered under a Group Health Insurance Policy? If so, take a look at the card. Look for the name of the group, a group number, the name of the insured and their social security number. Now take a look at the backside of the card. The backside of the card will usually contain the claims mailing address. The mailing address may or may not be the address of the insurance carrier who writes the policy. 19 P age

21 Sometimes insurance companies use a third party to administrate (pay, deny, reject, adjudicate) the claims. The third party is known as a TPA Third Party Administrator. This is what the backside of the Group Health Insurance Card may look like: Individual Insurance Policy If you are not employed, or if your employer does not provide Group Health Insurance Coverage, you may need to go directly to an insurance agent to purchase health insurance. When you do this, you are purchasing an Individual Insurance Policy or Plan. A policy number identifies the individual insurance policy. The insured is usually also identified by this number or their social security number and their name. Their date of birth may also appear on the card they receive. 20 P age

22 Medicare Medicare is a federal health insurance program for people 65 years of age or over and retired on Social Security, Railroad Retirement, or federal government retirement programs, individuals who have been legally disabled for more than 2 years, and persons with end-stage renal disease. There are 2 parts of Medicare. Medicare Part A is benefits covering in-patient hospital and skilled nursing facility services, hospice care, home health care, and blood transfusions. Medicare Part B is benefits covering outpatient hospital and health care provider services. If you are eligible for Medicare, you are identified by a Medicare Subscriber Number. Medicare is handled state by state. You will file your Medicare claims to the entity that has been chosen to administer these benefits in your state. A Medicare Card looks like this: Internet Resource Medicare Website 21 P age

23 Medicaid Medicaid is a combined federal/state medical assistance program that provides health and medical coverage benefits to persons on welfare. A number assigned by Medicaid usually identifies a Medicaid recipient. Below is an image of a Colorado Medicaid Authorization Card: Personal Injury/Medical Payments Coverage (auto) When you are involved in a motor vehicle accident your medical expenses are usually covered under the PIP (Personal Injury Protection) or Medical Payments Coverage of your automobile policy. When filing a claim form to an automobile insurance carrier, you will need to use the Claim Number assigned to the claim opened by the carrier. You will also need the Name of the Insurance Adjuster handling the claim as well as the address to mail the claim forms to. The date of the accident is also reported on the CMS 1500 claim form. 22 P age

24 Worker s Compensation Employers in all states except for Texas require worker s Compensation Insurance. Worker s Compensation (also called Work Comp in the medical billing industry) covers employee medical expenses and lost wages if they're hurt on the job. When filing a claim for workers compensation, you will typically need to use the Claim Number assigned by the insurance carrier or administrator. Sometimes a company/employer will administrate and pay medical expenses them self (Self Risk) and will require you to use the name and social security number of their employee. Internet Resource Workers Compensation Information Tricare (Civilian Health and Medical Program for the Uniformed Services) Tricare is a comprehensive federal civilian medical care program for spouses and dependents of those in the uniformed services, either active duty personnel or those who died while on active duty, as well as retired personnel, their spouses, and dependents. TRICARE is the government s health insurance program for all seven branches of uniformed services. 23 P age

25 Internet Resource Tricare Website Managed Care Plans (HMO, PPO, POS) There are three basic types of managed care plans: (1) Health Maintenance Organizations (HMOs), (2) Preferred Provider Organizations (PPOs), and (3) Point of Service (POS) plans. Although there are important differences between the different types of managed care plans, there are similarities as well. All managed care plans involve an arrangement between the insurer and a selected network of health care providers (doctors, hospitals, etc.). All offer policyholders significant financial incentives to use the providers in that network. There are usually specific 24 P age

26 standards for selecting providers and formal steps to ensure that quality care is delivered. Health Maintenance Organizations (HMOs) HMOs provide medical treatment on a prepaid basis, which means that HMO members pay a fixed monthly fee, regardless of how much medical care is needed in a given month. In return for this fee, most HMOs provide a wide variety of medical services, from office visits to hospitalization and surgery. With a few exceptions, HMO members must receive their medical treatment from physicians and facilities within the HMO network. Preferred Provider Organizations (PPOs) A PPO is made up of doctors and/or hospitals that provide medical service only to a specific group or association. Rather than prepaying for medical care, PPO members pay for services as they are rendered. The PPO sponsor (usually an employer or insurance company) generally reimburses the member for the cost of the treatment, less any co-payment. In some cases, the physician may submit the bill directly to the insurance company for payment. The insurer then pays the covered amount directly to the healthcare provider, and the member pays his or her co-payment amount. The price for each type of service is negotiated in advance by the healthcare providers and the PPO sponsor(s). Point of Service (POS) Plans A point of service plan is a type of managed healthcare system where you pay no deductible and usually only a minimal co-payment when you use a 25 P age

27 healthcare provider within your network. You also must choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside of the network for healthcare, you will likely be subject to a deductible (around $300 for an individual or $600 for a family), and your co-payment will be a substantial percentage of the physician's charges (usually 30-40%). Internet Resource Medline Plus Managed Care Plan Education Notes: 26 P age

28 Claims Processing Now that you have gathered the necessary data from the patient, you are ready to process your information for claim submission. When you are submitting a claim form to a payer you are actually submitting a bill. Some payers, such as attorneys, auto insurance carriers and worker s compensation carriers will accept, or sometimes prefer, an itemized statement as opposed to a CMS 1500 form. Since you will be using a Medical Billing / Practice Management software to track your claims (bills), you will most likely wish to create a claim form for each bill, and then perhaps also submit an itemized statement periodically to those payers who prefer them. Remember: The purpose of Chapter 1 Introduction to Medical Billing is to provide you with the basics overview of medical billing. We will reserve the details of completing the CMS 1500 Form for Chapter 3 Understanding the CMS 1500 Form. This section will be broken down as follows: 1. What is a CMS 1500 Form? 2. Breakdown of a CMS 1500 Form 3. Filing Claims a. Paper Claims b. Electronic Claims 4. Claim Acknowledgement a. Clearinghouse Acknowledgement 27 P age

29 b. Payer Acknowledgement 5. Receiving Payment 1. What is a CMS 1500 Form (formerly HCFA 1500 Form)? HCFA stands for Health Care Financing Administration. HCFA developed the HCFA 1500 Form (1-90) and required its use for all government claims. Subsequently, commercial insurance companies picked up the use of this form. On July 1, 2001, the Health Care Financing Administration (HCFA) became the Centers for Medicare & Medicaid Services (CMS). It's more than just a new name - it's an increased emphasis on responsiveness to beneficiaries and providers, and quality improvement. Thus, with this change, the HCFA 1500 was renamed to the CMS 1500 Form. The CMS 1500 Form (visual page 34) is used to report outpatient services rendered in a physician s office. For a complete listing of CMS Forms, you can visit the following URL address on the internet: 2. Breaking Down the CMS 1500 Form Simply put, there are 2 parts to the CMS 1500 Form. The top portion contains the information relating to the patient, the insured and the insurance policy. The bottom portion contains the information relating to the provider s office, procedures, and diagnosis. 28 P age

30 3. Filing Claims There are 2 methods for filing (submitting) a CMS 1500 Claim Form. The form can either be submitted on paper or submitted electronically using electronic data interchange (EDI). Most claims are filed electronically. a. Paper Claims Long ago, mailing a paper claim was necessary when filing a claim to the secondary insurance after the primary insurance had paid its portion. For instance, when a patient was covered by two insurance policies, the biller would file a claim to the primary insurance company first (either electronically or on paper). Once payment was received from the primary insurance company, a copy of the payment or Explanation of Benefits (EOB) had to be attached to a paper claim form and then filed (mailed) to the secondary insurance for further payment/consideration. These days, with regard to Medicare and Medicaid, Cross-Over Claims is the norm. Internet Resource E-How: What is a Cross-Over Claim? 29 P age

31 b. Electronic Claims Just as your Medical Billing Practice Management software gathers your inputted data and prints it out on a paper CMS 1500 form in the appropriate fields, it also has electronic claim formatting and submission capabilities. This process is called EDI Electronic Data Interchange. EDI submission involves an internet connection. Your claim information is gathered and placed into either a standard or print image format and then sent electronically to a clearinghouse or insurance carrier via an internet connection. Internet Resource Electronic Data Interchange (EDI) Terminology 4. Claim Acknowledgement Now that you have gathered the necessary data to prepare your CMS 1500 Claim Forms, checked them for accuracy and submitted them to insurance carriers, the next step is Claim Acknowledgment. You should know that just because you submitted a claim, this does not mean that the claim will be paid. The claim could be denied, rejected, never acknowledged (not received perhaps) or paid, but paid to the patient s deductible. This is why it is vital to have a system for tracking your claims. 30 P age

32 When you submit your claims electronically, either to a clearinghouse (most common method), or directly to an insurance carrier, you will normally receive back 2 Electronic Reports. Report 1: Clearinghouse Acknowledgment The clearinghouse acknowledges receipt of the claim. This report is usually submitted back to you immediately. Report 2: Payer Acknowledgment Indicates claims accepted and/or rejected by the payer. This report may be received a day or two after you submit the claims to your clearinghouse. The detail of this report may vary, but it can include the amount of payment to be made towards the claim. Internet Resource Zirmed Claims Clearinghouse For 13 years, in my Medical Billing Business, I used Zirmed. I gave you the link to Zirmed so that you can read about the process of Electronic (EDI) claims. If you find yourself in need of an Electronic Claims Clearinghouse, give us a call. We are able to provide Volume Discounts to our customers. (865) P age

33 5. Receiving Payment Payment of an insurance claim typically comes in the form of a check or an EFT (Electronic Funds Transfer) with an attached breakdown of the date(s) of service, procedures performed (CPT Codes) and charges. It will also provide reasons why a procedure was denied, rejected, not paid or partially paid. This breakdown detail is called the Explanation of Benefits (EOB). Checks for claim payment and EOB s, in most cases, are sent directly to the provider (physician s office). Generating Reports At the end of each day you will want to generate a Day Sheet Report to make sure the figures in your system match the actual charge and payment figures of the practice. It is advisable to also run a Transaction Report at the end of each week for the entire week worth of charges and payments. At the end of each month, you will want to generate certain Production Reports for your client/practice and for yourself. Reports will vary based upon the needs of the practice and the needs of the billing center business. Billing Services: If you are charging for your services based upon a Percentage of Collections (most common method of charging), you will want to generate a Payment Report that reflects the money received for the month, if you are billing your client on a monthly basis. 32 P age

34 CHAPTER 1 STUDY GUIDE Visuals & Notes 33 P age

35 Sample Superbill / Encounter Document 34 P age

36 Sample Completed CMS 1500 Form 35 P age

37 Notes: 36 P age

38 Notes: 37 P age

39 Chapter 1 Examination If you are a Registered NAHAEC Student, you will need to return to the Student Area to complete your online exam. Recording your answers here first will make the online process easier. If you have not yet registered as a student, simply go to Complete the information, choose a course program and submit. 1. In order to become a medical biller, one must receive the following certification: a. MBC Medical Billing Certification b. Certification from an Accredited College Course c. Certification from a Medical Software Vendor d. There are currently no certification requirements to be a medical biller, although it is highly recommended 2. Medical Billing & Medical Coding are one in the same True False 3. List the 12 duties typically performed by the medical biller a. b. c. d. e. f. g. 38 P age

40 h. i. j. k. l. 4. What are the 5 pieces of information needed from a patient in order to complete the CMS 1500 Form? a. b. c. d. e. 5. Name the 8 most common types of insurance coverage: a. b. c. d. e. f. g. h. 39 P age

41 6. What does CPT stand for? 7. For billing purposes, you use a CPT Code to report a. the diagnosis of a patient b. annually c. the procedure performed on the patient 8. CPT Codes are published and maintained by the 9. ICD stands for 10. On a Group Health Insurance Card, the Group typically represents: a. The Insurance Company b. The Employer c. The Patient s Family 11. An agency hired by an insurance company for the purpose of administrating their Insurance Policy Claims Benefits is called a: 12. Name the 2 Parts of Medicare Coverage a. b. 40 P age

42 13. If you are eligible for Medicare, you are identified by a 14. Medicaid is a combined federal / state medical assistance program that provides health and medical coverage benefits to a person who is on 15. Tricare is a comprehensive federal civilian medical care program for spouses and dependents of those in a. The Uniformed Services b. Government Held Positions c. The Medical Field 16. When you are submitting a claim form to a payer you are actually submitting a a. bill b. receipt c. remittance 17. What does HCFA stand for? 18. What does CMS stand for? 19. The CMS 1500 Form is used to report services rendered in a physician s office. 41 P age

43 20. What is an EOB? 21. What is the process in which your Medical Billing Practice Management software system takes inputted data and formats it to be submitted electronically? 22. Upon submission of an electronic claim, the clearinghouse will send you back an Acknowledgement Report. This report acknowledges: a. that your software program is working b. the name of the physician c. receipt of the claim 42 P age

44 What s Coming in Chapter 2 In Chapter 2 Understanding Office Forms, we will explore the office forms, documents and contracts commonly found in the medical office. In Chapter 2B, we will teach you how to accurately complete the Insurance Verification Process. Motivation If you think you can, you can. If you think you can t, You re right. -Mary Kay Ash Constant effort and frequent Mistakes are the stepping Stones to genius. -Elbert Hubbard Take time to deliberate, but When the time for action has Arrived, stop thinking and go in. -Napoleon Bonaparte 43 P age

45 A Word from the Developer First and foremost, I want to remind you to not be overwhelmed by this chapter. As an overview, this chapter touches on many aspects of the medical billing position. In future chapters, we break down each aspect in detail. If you are a registered NAHAEC student, remember that you have several avenues of support. Use them if need be. We are here to make this an awesome certification experience for you! My Personal History in Medical Billing My name is Tammy Harlan and I ve been in the medical billing industry for 24 years. This industry has supported my family for 24 years. The industry has also supported my twin sister, Debby and her family, for 20 years, and my youngest son for 7 years now. Over the years, I have assisted hundreds of people in beginning a medical billing business, whose families have been supported for many years in this industry as well. I m sure it is not by chance that you have entered into this industry. It is the fastest growing industry of our time which means it is the place where the jobs and the money are. If you would like to read my bio, BC Advantage Billing & Coding has it listed at If you would like to read about how I got started in this business, I provide the first 4 chapters of my Medical Billing Business Marketing Resource Guide for free. Click on the following link to get it: Best Wishes! Tammy 44 P age