MENTAL DISORDERS [290-319]
[290-299] Psychoses.
[290-294] Organic psychotic conditions.
[295-299] Other psychoses.
[300-316] Neurotic disorders, personality disorders, and other non-psychotic mental disorders.
[317-319] Mental retardation.
NERVOUS SYSTEM AND SENSE ORGANS [320-389]
[320-326] Inflammatory diseases of the central nervous system.
[330-337] Hereditary and degenerative diseases of the central nervous system.
[340-349] Other disorders of the central nervous system.
[350-359] Disorders of the peripheral nervous system.
[360-379] Disorders of the eye and adnexa.
[380-389] Diseases of the ear and mstoid process.
DISEASES OF THE CIRCULATORY SYSTEM [390-459]
[390-392] Acute rheumatic fever.
[393-398] Chronic rheumatic heart disease.
[401-405] Hypertensive disease.
[410-414] Ischemic heart disease.
[415-417] Diseases of pulmonary circulation.
[420-429] Other forms of heart disease.
[430-438] Cerebrovascular disease.
[440-448] Diseases of arteries, arterioles, and capillaries.
[451-459] Diseases of veins and lymphatics, and other diseases of circulatory system
Tuesday, August 30, 2011
Monday, August 29, 2011
Medical Billing Fraud & abuse
Fraud, waste and abuse prevention & training
If you identify potential fraud, waste, or abuse, please report it to us immediately so that we can investigate and respond appropriately. Please see the How to Contact Us section of this guide for contact information. Please note UnitedHealthcare expressly prohibits retaliation if a report is made in good faith.
• Fraud Is a false statement, made or submitted by an individual or entity, who knows that the statement is false, and knows that the false statement could result in some otherwise unauthorized benefit to the individual or entity. These false statements could be verbal or written.
• Waste Generally means over-use of services, or other practices that result in unnecessary costs. In most cases, waste is not considered caused by reckless actions but rather the misuse of resources.
• Abuse Generally refers to provider, contractor or member practices that are inconsistent with sound business, financial or medical practices; and that cause unnecessary costs to the health care system.
Effective January 1, 2009, the Centers for Medicare & Medicaid Services (“CMS”) modified certain rules and regulations of the Medicare Advantage and the Part D programs. The rules state that a compliance plan must include training, education, and effective lines of communication between the compliance officer and the organization’s employees, managers, directors, as well as first tier, downstream and related entities. This change clarified that plan sponsors, such as UnitedHealthcare, need to apply these training and communication requirements to all entities they are partnering with to provide services in Medicare Advantage or Part D programs.
As a contracted provider for UnitedHealthcare’s Medicare Advantage programs, you are considered a first tier or downstream entity and are subject to this CMS requirement. It is our responsibility to ensure that your organization is provided with appropriate training for your employees and applicable subcontractors. To facilitate that, we will be providing your organization with training materials, which will be made available on UnitedHealthcareOnline.com.
Annually, your organization must administer the training materials to your employees and applicable subcontractors. This annual training can be done using our materials or you may use your existing training program and/or materials provided by another health plan as long as that training meets the CMS requirements. Please maintain records of the training (i.e. sign-in sheets, materials, etc). Documentation of the training may be requested by UnitedHealthcare, CMS, or an agent of CMS to verify the training was completed.
If you identify potential fraud, waste, or abuse, please report it to us immediately so that we can investigate and respond appropriately. Please see the How to Contact Us section of this guide for contact information. Please note UnitedHealthcare expressly prohibits retaliation if a report is made in good faith.
• Fraud Is a false statement, made or submitted by an individual or entity, who knows that the statement is false, and knows that the false statement could result in some otherwise unauthorized benefit to the individual or entity. These false statements could be verbal or written.
• Waste Generally means over-use of services, or other practices that result in unnecessary costs. In most cases, waste is not considered caused by reckless actions but rather the misuse of resources.
• Abuse Generally refers to provider, contractor or member practices that are inconsistent with sound business, financial or medical practices; and that cause unnecessary costs to the health care system.
Effective January 1, 2009, the Centers for Medicare & Medicaid Services (“CMS”) modified certain rules and regulations of the Medicare Advantage and the Part D programs. The rules state that a compliance plan must include training, education, and effective lines of communication between the compliance officer and the organization’s employees, managers, directors, as well as first tier, downstream and related entities. This change clarified that plan sponsors, such as UnitedHealthcare, need to apply these training and communication requirements to all entities they are partnering with to provide services in Medicare Advantage or Part D programs.
As a contracted provider for UnitedHealthcare’s Medicare Advantage programs, you are considered a first tier or downstream entity and are subject to this CMS requirement. It is our responsibility to ensure that your organization is provided with appropriate training for your employees and applicable subcontractors. To facilitate that, we will be providing your organization with training materials, which will be made available on UnitedHealthcareOnline.com.
Annually, your organization must administer the training materials to your employees and applicable subcontractors. This annual training can be done using our materials or you may use your existing training program and/or materials provided by another health plan as long as that training meets the CMS requirements. Please maintain records of the training (i.e. sign-in sheets, materials, etc). Documentation of the training may be requested by UnitedHealthcare, CMS, or an agent of CMS to verify the training was completed.
How To File an Adjustment Request on a Paper Claim
Requirements for Filing an Adjustment
An adjustment request is processed as a replacement to the original, incorrectly paid claim. The original payment for the claim is completely deducted. All claim items on the request must be correctly completed. An adjustment must be for the entire amount, not just for remaining unpaid amounts or units.
A legible photocopy of the original claim or an entirely new claim can be used when submitting an adjustment.
The provider does not need to send an adjustment request for each claim line that paid incorrectly. All errors can be corrected with one adjustment request.
Adjustments must be received by the Medicaid fiscal agent within one year of the date of payment.
Partially Incorrect Claim Lines on a Claim Form
Use the following procedures when some claim lines on a claim form paid correctly and other lines did not pay correctly.
If some claim lines paid correctly and some lines denied, do not request an adjustment. Cross out the claim lines that were paid, change the total amount billed, correct the errors on the lines that denied, and resubmit the claim. If all the claim lines paid, but some paid incorrectly, request an adjustment.
Make needed corrections and circle the items to be corrected in black ink. Do not cross out the lines that paid correctly. Crossed-out lines are treated as voids and payment for these lines will be recouped.
If one claim line needs to be deleted from a claim that has other lines that paid correctly, request an adjustment not a void. If the request is marked as a void, all the claim lines will be recouped. To delete one line, mark the request an adjustment, circle the line to be deleted, and write “delete” to the side of the line.
You must use black ink.
Adjustment Instructions
When requesting an adjustment or void, the provider must:
· Resubmit a photocopy of the original claim or a new claim form;
· Enter the items listed below;
· Ensure that the items on the adjusted claim match the items on the original
claim, except for the corrections that are made and circled in black ink;
· Initial and date the form if it is a photocopy, or sign and date it if it is a new
form;
· Attach copies of the documents that were required for the original claim to
the adjustment request; and
· Mail the adjustment or void request to the fiscal agent for processing to:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080
Thursday, August 25, 2011
Can we take Medical Insurance Biller and Coder as a job?
A person working within the profession of medical insurance billers or medical insurance coder’s works in the administrative sector of the medical field, managing patient records and database information, following up on billing for insurance and book-keeping/accounting for the practice or healthcare facility. Insurance billers and coders that work in a front office utilize their expertise without having any direct interaction with patients.
A career in medical insurance billing and coding is ideal for a person looking for a job concerning the analysis of data with a focus on implementing a coding system that is used to identify and group various items. Whereas a medical biller implements a preset code, a medical coder focuses on allocating codes for the different procedures.
Each and every medical diagnosis and medical procedure used within a healthcare facility must have an appropriate code assignment. This allows the office to file a successful claim for settlement from an insurance company. Medical insurance billers and coders can work in doctor's practice, within a hospital, or even at a dedicated healthcare office. A fair amount of medical billers and coders choose to work for agencies that offer their resources to healthcare facilities on a freelance basis, outsourcing members of staff.
Medical insurance billing and coding is an exciting field of work that appeals to and suits people who have great attention to detail. Coders and billers must also be able to efficiently adapt to industry standards. Errors and inaccuracies within the profession can lead to mis-selling a particular service or under pricing a product, incorrect or incompatible coding, and even misplacement of claims and payments that more often than not contribute to loss of income in a medical practice.
Such is the requirement for efficient and error-free coding that a high value is placed on those who are very effective and proficient in their area of work. Medical insurance billers and coders find work in areas that include, but are by no means limited to doctor’s practices, billing agencies, medical care clinics and healthcare facilities. Many employers favor potential candidates with greater certifications or more advanced qualifications. Certifications can often help ensure that potential candidates have the right skills and as a consequence, secure a more successful job.
Certification for insurance billing and coding combined with work experience that is earned while working is something employers will use to determine potential candidates for advancing into managerial positions as well as bespoke posts within a company that call for specific skills and expertise.
A career in medical insurance billing and coding is ideal for a person looking for a job concerning the analysis of data with a focus on implementing a coding system that is used to identify and group various items. Whereas a medical biller implements a preset code, a medical coder focuses on allocating codes for the different procedures.
Each and every medical diagnosis and medical procedure used within a healthcare facility must have an appropriate code assignment. This allows the office to file a successful claim for settlement from an insurance company. Medical insurance billers and coders can work in doctor's practice, within a hospital, or even at a dedicated healthcare office. A fair amount of medical billers and coders choose to work for agencies that offer their resources to healthcare facilities on a freelance basis, outsourcing members of staff.
Medical insurance billing and coding is an exciting field of work that appeals to and suits people who have great attention to detail. Coders and billers must also be able to efficiently adapt to industry standards. Errors and inaccuracies within the profession can lead to mis-selling a particular service or under pricing a product, incorrect or incompatible coding, and even misplacement of claims and payments that more often than not contribute to loss of income in a medical practice.
Such is the requirement for efficient and error-free coding that a high value is placed on those who are very effective and proficient in their area of work. Medical insurance billers and coders find work in areas that include, but are by no means limited to doctor’s practices, billing agencies, medical care clinics and healthcare facilities. Many employers favor potential candidates with greater certifications or more advanced qualifications. Certifications can often help ensure that potential candidates have the right skills and as a consequence, secure a more successful job.
Certification for insurance billing and coding combined with work experience that is earned while working is something employers will use to determine potential candidates for advancing into managerial positions as well as bespoke posts within a company that call for specific skills and expertise.
Wednesday, August 24, 2011
Standard for Medical records - General Guidelines
Medical record standards
Medical records will contain all information necessary and appropriate for quality improvement activities and to support claims for services submitted by you.
In providing care for UnitedHealthcare members, we expect that you have signed, written policies to address the following (critical elements appear in bold text in this section):
1. Maintain a single, permanent medical record that is current, detailed, organized and comprehensive for each
member and is available at each visit.
2. Protect member records, whether in paper or electronic form, against loss, destruction, tampering or
unauthorized use. For electronic medical records, you must establish security safeguards in order to prevent
unauthorized access or alteration of records without leaving an audit trail to identify the breach. Such safeguards must be programmed so that they cannot be overridden or turned off.
3. Maintain medical records in a confidential manner and provide periodic training to office staff
regarding confidentiality processes. Records storage must allow for easy retrieval, be secure and allow
access only by authorized personnel.
4. Maintain a mechanism for monitoring and handling missed appointments.
5. Demonstrate the office does not discriminate in the delivery of health care.
General documentation guidelines
We also expect you to follow these commonly accepted guidelines for medical record information and documentation:
• Date all entries, and identify the author and their credentials when applicable. For records generated by word processing software or electronic medical record software, the documentation should include all authors and their credentials. It should be apparent from the documentation which individual performed a given service.
• Clearly label or document subsequent changes to a medical record entry by including the author of the change and date of change. The provider must also maintain a copy of the original entry.
• Generate documentation at the time of service or shortly thereafter.
• Make entries legible.
• Cite medical conditions and significant illnesses on a problem list and document clinical findings and
evaluation for each visit.
• Documentation that is not reasonable and necessary for the diagnosis or treatment of an injury or illness or to
improve the function of a malformed body member (over documentation) should not be considered when selecting the appropriate level of an E&M service. Only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate E&M level.
• Give prominence to notes on medication allergies and adverse reactions. Also, note if the member has
no known allergies or adverse reactions.
• Make it easy to identify the medical history, and include chronic illnesses, accidents and operations.
• For medication records, include name of medication and dosages. Also, list over the counter drugs
taken by the member.
• Records reflect all services provided, ancillary services/tests ordered, and all diagnostic/therapeutic services referred by the physician/health care professional.
• Clearly label any documentation generated at a previous visit as previously obtained, if it is included in the
current record.
Document these important items:
• Tobacco habits, including advice to quit, alcohol use and substance abuse for members age eleven (11) and older
• Immunization record
• Family and social history
• Preventive screenings/services and risk screenings
• Screening for depression and evidence of coordination with behavioral health providers
• Blood pressure, height and weight, body mass index
Medical records will contain all information necessary and appropriate for quality improvement activities and to support claims for services submitted by you.
In providing care for UnitedHealthcare members, we expect that you have signed, written policies to address the following (critical elements appear in bold text in this section):
1. Maintain a single, permanent medical record that is current, detailed, organized and comprehensive for each
member and is available at each visit.
2. Protect member records, whether in paper or electronic form, against loss, destruction, tampering or
unauthorized use. For electronic medical records, you must establish security safeguards in order to prevent
unauthorized access or alteration of records without leaving an audit trail to identify the breach. Such safeguards must be programmed so that they cannot be overridden or turned off.
3. Maintain medical records in a confidential manner and provide periodic training to office staff
regarding confidentiality processes. Records storage must allow for easy retrieval, be secure and allow
access only by authorized personnel.
4. Maintain a mechanism for monitoring and handling missed appointments.
5. Demonstrate the office does not discriminate in the delivery of health care.
General documentation guidelines
We also expect you to follow these commonly accepted guidelines for medical record information and documentation:
• Date all entries, and identify the author and their credentials when applicable. For records generated by word processing software or electronic medical record software, the documentation should include all authors and their credentials. It should be apparent from the documentation which individual performed a given service.
• Clearly label or document subsequent changes to a medical record entry by including the author of the change and date of change. The provider must also maintain a copy of the original entry.
• Generate documentation at the time of service or shortly thereafter.
• Make entries legible.
• Cite medical conditions and significant illnesses on a problem list and document clinical findings and
evaluation for each visit.
• Documentation that is not reasonable and necessary for the diagnosis or treatment of an injury or illness or to
improve the function of a malformed body member (over documentation) should not be considered when selecting the appropriate level of an E&M service. Only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate E&M level.
• Give prominence to notes on medication allergies and adverse reactions. Also, note if the member has
no known allergies or adverse reactions.
• Make it easy to identify the medical history, and include chronic illnesses, accidents and operations.
• For medication records, include name of medication and dosages. Also, list over the counter drugs
taken by the member.
• Records reflect all services provided, ancillary services/tests ordered, and all diagnostic/therapeutic services referred by the physician/health care professional.
• Clearly label any documentation generated at a previous visit as previously obtained, if it is included in the
current record.
Document these important items:
• Tobacco habits, including advice to quit, alcohol use and substance abuse for members age eleven (11) and older
• Immunization record
• Family and social history
• Preventive screenings/services and risk screenings
• Screening for depression and evidence of coordination with behavioral health providers
• Blood pressure, height and weight, body mass index
Sunday, August 21, 2011
Billing patient for non - covered service - consent form
Charging members for non-covered services
For Commercial members, you may seek and collect payment from our member for services not covered under the applicable benefit plan, provided you first obtain the member’s written consent. Such consent must be signed and dated by the member prior to rendering the specific service(s) in question. Retain a copy of this consent in the member’s medical record. In those instances in which you know or have reason to know that the service may not be covered (as described below), the written consent also must: (a) include an estimate of the charges for that service; (b) include a statement of reason for your belief that the service may not be covered; and (c) in the case of a determination by us that planned services are not covered services, include a statement that UnitedHealthcare has determined that the service is not covered and that the member, with knowledge of UnitedHealthcare’s determination, agrees to be responsible for those charges.
For Medicare Advantage members, a Notice of Denial of Medical Coverage must be provided to the member advising them when a service is not covered.
You should know or have reason to know that a service may not be covered if:
•
We have provided general notice through an article in a newsletter or bulletin, or information provided on our Web site (UnitedHealthcareOnline.com), including clinical protocols, medical and drug policies, either that we will not cover a particular service or that a particular service will be covered only under certain circumstances not present with the member; or
• We have made a determination that planned services are not covered services and have communicated that
determination to you on this or a previous occasion.
You must not bill our member for non-covered services if you do not comply with this Protocol.
If you do not obtain written consent as specified above, the rendering provider must accept full financial liability for the cost of care. General agreements to pay, such as those signed by the member at any time (including at admission or upon the initial office visit), are not considered written consent under this Protocol.
For Commercial members, you may seek and collect payment from our member for services not covered under the applicable benefit plan, provided you first obtain the member’s written consent. Such consent must be signed and dated by the member prior to rendering the specific service(s) in question. Retain a copy of this consent in the member’s medical record. In those instances in which you know or have reason to know that the service may not be covered (as described below), the written consent also must: (a) include an estimate of the charges for that service; (b) include a statement of reason for your belief that the service may not be covered; and (c) in the case of a determination by us that planned services are not covered services, include a statement that UnitedHealthcare has determined that the service is not covered and that the member, with knowledge of UnitedHealthcare’s determination, agrees to be responsible for those charges.
For Medicare Advantage members, a Notice of Denial of Medical Coverage must be provided to the member advising them when a service is not covered.
You should know or have reason to know that a service may not be covered if:
•
We have provided general notice through an article in a newsletter or bulletin, or information provided on our Web site (UnitedHealthcareOnline.com), including clinical protocols, medical and drug policies, either that we will not cover a particular service or that a particular service will be covered only under certain circumstances not present with the member; or
• We have made a determination that planned services are not covered services and have communicated that
determination to you on this or a previous occasion.
You must not bill our member for non-covered services if you do not comply with this Protocol.
If you do not obtain written consent as specified above, the rendering provider must accept full financial liability for the cost of care. General agreements to pay, such as those signed by the member at any time (including at admission or upon the initial office visit), are not considered written consent under this Protocol.
Saturday, August 20, 2011
NEOPLASMS, ENDOCRINE, BLOOD-FORMING ORGANS DX list
NEOPLASMS [140-239]
[140-149] Malignant neoplasm of lip, oral cavity, and pharynx.
[150-159] Malignant neoplasm of digestive organs and peritoneum.
[160-165] Malignant neoplasm of respiratory and intrathoracic organs.
[170-176] Malignant neoplasm of bone, connective tissue, skin, and breast.
[179-189] Malignant neoplasm of genitourinary organs.
[190-199] Malignant neoplasm of other and unspecified sites.
[200-208] Malignant neoplasm of lymphatic and hematopoietic tissue.
[210-229] Benign neoplasms.
[230-234] Carcinoma in situ.
[235-238] Neoplasms of uncertain behavior.
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES,AND IMMUNITY DISORDERS [240-279]
[240-246] Disorders of thyroid gland.
[250-259] Diseases of other endocrine glands.
[260-269] Nutritional deficiencies.
[270-279] Other metabolic and immunity disorders.
DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS [280-289]
[280-285] Anemias.
[286-287] Coagulation and hemorrhagic disorders.
[288-288] Diseases of white blood cells.
[289-289] Other diseases of blood and blood-forming organs.
[140-149] Malignant neoplasm of lip, oral cavity, and pharynx.
[150-159] Malignant neoplasm of digestive organs and peritoneum.
[160-165] Malignant neoplasm of respiratory and intrathoracic organs.
[170-176] Malignant neoplasm of bone, connective tissue, skin, and breast.
[179-189] Malignant neoplasm of genitourinary organs.
[190-199] Malignant neoplasm of other and unspecified sites.
[200-208] Malignant neoplasm of lymphatic and hematopoietic tissue.
[210-229] Benign neoplasms.
[230-234] Carcinoma in situ.
[235-238] Neoplasms of uncertain behavior.
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES,AND IMMUNITY DISORDERS [240-279]
[240-246] Disorders of thyroid gland.
[250-259] Diseases of other endocrine glands.
[260-269] Nutritional deficiencies.
[270-279] Other metabolic and immunity disorders.
DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS [280-289]
[280-285] Anemias.
[286-287] Coagulation and hemorrhagic disorders.
[288-288] Diseases of white blood cells.
[289-289] Other diseases of blood and blood-forming organs.
Thursday, August 18, 2011
Surgery CPT code list
• CPT Codes listed by body system
Integumentary 10021 - 19499
Musculoskeletal 20000 - 29999
Respiratory 30000 - 32999
Cardiovascular 33010 - 37799
Hemic and Lymphatic 38100 - 38999
Mediastinum and Diaphragm 39000 - 39599
Digestive 40490 - 49999
Urinary 50010 - 53899
Male Genital 54000 - 55899
Intersex Surgery 55970 - 55980
Female Genital 56405 - 58999
Maternity Care and Delivery 59000 - 59899
Endocrine 60000 - 60699
Nervous 61000 - 64999
Eye and Ocular Adnexa 65091 - 68899
Auditory 69000 - 69979
Operating Microscope +69990
Integumentary 10021 - 19499
Musculoskeletal 20000 - 29999
Respiratory 30000 - 32999
Cardiovascular 33010 - 37799
Hemic and Lymphatic 38100 - 38999
Mediastinum and Diaphragm 39000 - 39599
Digestive 40490 - 49999
Urinary 50010 - 53899
Male Genital 54000 - 55899
Intersex Surgery 55970 - 55980
Female Genital 56405 - 58999
Maternity Care and Delivery 59000 - 59899
Endocrine 60000 - 60699
Nervous 61000 - 64999
Eye and Ocular Adnexa 65091 - 68899
Auditory 69000 - 69979
Operating Microscope +69990
Tuesday, August 16, 2011
Affordable Medical Billing Services for Physicians
Just like managing business accounts of any other company, medical billing comes with its own sets of rules and complexities. There are a lot of procedures to take care of and at the same time continue providing efficient, accurate and quality service. Then you also have to be worried about the insurance company which is sure to go over the billing system with a magnifying glass. One single mistake is going to cost you dearly and will leave a bad impact on the reputation of your medical facility irrespective of the quality of service you have provided to the patients. All in all, just like medical treatment should best be left to general physicians & specialist doctors, similarly the medical billing system of hospitals and clinics should be handed over to the professionals to manage.
Contrary to popular belief, outsourcing medical billing systems are not only for the big hospitals and treatment centers. Even medium sized medical facilities, diagnostic centers and healthcare clinics will be better off by investing in medical billing system to manage the collection of medical bills. The medical bills include everything ranging from consultation fee and cost of tests, right down to cost of treatments, operations and medicine. When you have found some company to handle the billing, you can get down to solving other administrative issues in your medical facility.
The best part about these medical billing companies is that they offer very affordable packages for everyone. The packages are so attractive that it is even affordable for a general physician to hire the company to handle the accounts in his small medical clinic. These companies have well-qualified and trained staff that can handle all your tasks including transcription services, claim submission, claim transmission, charge entry and audit, authorizations, payment posting, wellness checks, patient checks and denial resolutions among others. Not only this, but these companies will streamline your entire medical billing system to reduce time and effort required to manage the system. They will also help you in reducing the number of claim rejections for your medical facility.
Moreover once you have hired the right company you do not have to worry about complying with the laws and regulations of insurance companies and health regulatory authorities. Your hired company will make sure that everything goes according to the laws.
So what are you waiting for? Go online and find a medical billing service to outsource this job a reputed and experienced company.
Contrary to popular belief, outsourcing medical billing systems are not only for the big hospitals and treatment centers. Even medium sized medical facilities, diagnostic centers and healthcare clinics will be better off by investing in medical billing system to manage the collection of medical bills. The medical bills include everything ranging from consultation fee and cost of tests, right down to cost of treatments, operations and medicine. When you have found some company to handle the billing, you can get down to solving other administrative issues in your medical facility.
The best part about these medical billing companies is that they offer very affordable packages for everyone. The packages are so attractive that it is even affordable for a general physician to hire the company to handle the accounts in his small medical clinic. These companies have well-qualified and trained staff that can handle all your tasks including transcription services, claim submission, claim transmission, charge entry and audit, authorizations, payment posting, wellness checks, patient checks and denial resolutions among others. Not only this, but these companies will streamline your entire medical billing system to reduce time and effort required to manage the system. They will also help you in reducing the number of claim rejections for your medical facility.
Moreover once you have hired the right company you do not have to worry about complying with the laws and regulations of insurance companies and health regulatory authorities. Your hired company will make sure that everything goes according to the laws.
So what are you waiting for? Go online and find a medical billing service to outsource this job a reputed and experienced company.
Saturday, August 13, 2011
Transplant Services CPT code list
Request for transplant or transplant-related services prior to pre-treatment or evaluation,
including the following CPT Procedure Codes for Specifically Requested Transplantations:
BONE MARROW - Peripheral Stem Cell
38230 Bone marrow harvesting for transplantation
38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic
38241 Bone marrow or blood-derived peripheral stem cell transplantation; autologous
38242 Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor
lymphocyte infusions
HEART / LUNG
33930 D onor cardiectomy-pneumonectomy, with preparation and maintenance of allograft
33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy
HEART
33940 D onor cardiectomy, with preparation and maintenance of allograft
33945 Heart transplant, with or without recipient cardiectomy
0051T I mplantation of a total replacement heart system (artificial heart) with recipient
cardiectomy
0052T Replacement or repair of thoracic unit of a total replacement heart system
(artificial heart)
0053T Replacement or repair of implantable component or components of total replacement
heart system (artificial heart), excluding thoracic unit
LUNG
32850 D onor pneumonectomy(ies) with preparation and maintenance of allograft (cadaver)
32851 L ung transplant, single; without cardiopulmonary bypass
32852 with cardiopulmonary bypass
32853 L ung transplant, double (bilateral sequential or en bloc); without cardiopulmonary
bypass
32854 with cardiopulmonary bypass
KIDNEY
50300 D onor nephrectomy, with preparation and maintenance of allograft, from cadaver donor,
unilateral or bilateral
50320 D onor nephrectomy, open from living donor (excluding preparation and maintenance of
allograft)
50340 Recipient nephrectomy
50360 Renal allotransplantation, implantation of graft; excluding donor and recipient
nephrectomy
50365 with recipient nephrectomy
50370 Removal of transplanted renal allograft
50380 Renal autotransplantation, reimplantation of kidney
50547 L aparoscopic donor nephrectomy from living donor (excluding preparation and
maintenance of allograft)
PANCREAS
48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or
pancreatic islet cells
48550 D onor pancreatectomy, with preparation and maintenance of allograft from cadaver
donor, with or without duodenal segment for transplantation
48554 Transplantation of pancreatic allograft
48556 Removal of transplanted pancreatic allograft
LIVER
47135 L iver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any
age
47136 heterotopic, partial or whole, from cadaver or living donor, any age
INTESTINE
44132 D onor enterectomy, open, with preparation and maintenance of allograft; from cadaver
donor
44133 partial, from living donor
44135 I ntestinal allotransplantation; from cadaver donor
44136 from living donor
including the following CPT Procedure Codes for Specifically Requested Transplantations:
BONE MARROW - Peripheral Stem Cell
38230 Bone marrow harvesting for transplantation
38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic
38241 Bone marrow or blood-derived peripheral stem cell transplantation; autologous
38242 Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor
lymphocyte infusions
HEART / LUNG
33930 D onor cardiectomy-pneumonectomy, with preparation and maintenance of allograft
33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy
HEART
33940 D onor cardiectomy, with preparation and maintenance of allograft
33945 Heart transplant, with or without recipient cardiectomy
0051T I mplantation of a total replacement heart system (artificial heart) with recipient
cardiectomy
0052T Replacement or repair of thoracic unit of a total replacement heart system
(artificial heart)
0053T Replacement or repair of implantable component or components of total replacement
heart system (artificial heart), excluding thoracic unit
LUNG
32850 D onor pneumonectomy(ies) with preparation and maintenance of allograft (cadaver)
32851 L ung transplant, single; without cardiopulmonary bypass
32852 with cardiopulmonary bypass
32853 L ung transplant, double (bilateral sequential or en bloc); without cardiopulmonary
bypass
32854 with cardiopulmonary bypass
KIDNEY
50300 D onor nephrectomy, with preparation and maintenance of allograft, from cadaver donor,
unilateral or bilateral
50320 D onor nephrectomy, open from living donor (excluding preparation and maintenance of
allograft)
50340 Recipient nephrectomy
50360 Renal allotransplantation, implantation of graft; excluding donor and recipient
nephrectomy
50365 with recipient nephrectomy
50370 Removal of transplanted renal allograft
50380 Renal autotransplantation, reimplantation of kidney
50547 L aparoscopic donor nephrectomy from living donor (excluding preparation and
maintenance of allograft)
PANCREAS
48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or
pancreatic islet cells
48550 D onor pancreatectomy, with preparation and maintenance of allograft from cadaver
donor, with or without duodenal segment for transplantation
48554 Transplantation of pancreatic allograft
48556 Removal of transplanted pancreatic allograft
LIVER
47135 L iver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any
age
47136 heterotopic, partial or whole, from cadaver or living donor, any age
INTESTINE
44132 D onor enterectomy, open, with preparation and maintenance of allograft; from cadaver
donor
44133 partial, from living donor
44135 I ntestinal allotransplantation; from cadaver donor
44136 from living donor
Wednesday, August 10, 2011
INFECTIOUS AND PARASITIC DISEASES [001-139] - DX code
[001-009] Intestinal infectious diseases.
[010-018] Tuberculosis.
[020-027] Zoonotic bacterial diseases.
[030-041] Other bacterial diseases.
[042-042] Human immunodeficiency virus (hiv) infection.
[045-049] Poliomyelitis and other non-arthropod-borne viral diseases of central nervous
system.
[050-057] Viral diseases accompanied by exam.
[060-066] Arthropod-borne viral disease.
[070-079] Other diseases due to viruses and chlamydia.
[080-088] Rickettsioses and other arthropod-borne diseases.
[090-099] Syphilis and other venereal diseases.
[100-104] Other spirochetal diseases.
[110-118] Mycoses.
[120-129] Helminthiases.
[130-136] Other infectious and parasitic diseases.
[137-139] Late effects of infectious and parasitic diseases.
[010-018] Tuberculosis.
[020-027] Zoonotic bacterial diseases.
[030-041] Other bacterial diseases.
[042-042] Human immunodeficiency virus (hiv) infection.
[045-049] Poliomyelitis and other non-arthropod-borne viral diseases of central nervous
system.
[050-057] Viral diseases accompanied by exam.
[060-066] Arthropod-borne viral disease.
[070-079] Other diseases due to viruses and chlamydia.
[080-088] Rickettsioses and other arthropod-borne diseases.
[090-099] Syphilis and other venereal diseases.
[100-104] Other spirochetal diseases.
[110-118] Mycoses.
[120-129] Helminthiases.
[130-136] Other infectious and parasitic diseases.
[137-139] Late effects of infectious and parasitic diseases.
Medicare supplement coverage plan responsibilities - Medicare select
What Is Medicare Select?
Medicare Select is a Medicare Supplement product available only to AARP® members who reside within the service area of a hospital which participates in our Medicare Select network. It is a lower cost alternative to Standardized
Medicare Supplement coverage.
Responsibilities of Medicare Select members
To offer the plan at a lower premium, we require that Medicare Select members utilize a participating hospital for all inpatient and outpatient hospital services (except emergency care and services provided when members are outside of their service area).
Hospital responsibilities
Participating hospitals agree to a reduced/waived reimbursement of Medicare’s Part A In-Hospital deductible. Cost savings associated with hospitals’ reduction/waiver of Medicare’s Part A In-Hospital deductible are passed on to Medicare Select members in the form of lower premium cost.
To submit a Medicare Part A or Part B Intermediary claim for a Medicare Select insured, mail a copy of the standard
CMS billing form along with a Medicare Explanation of Benefits or Medicare Remittance Advice to:
AARP® Medicare Select
UnitedHealthcare Claim Division
P.O. Box 740819
Atlanta, GA 30374-0819
Note: Medicare Part B claims billed to a Medicare carrier are, in most cases, received electronically from the
Medicare carrier.
To promote timely processing on all claim submissions, follow standardized Medicare billing practices. Be sure to include the 11-digit AARP® Medicare Select member’s health care ID number on the standard CMS billing form.
What does Medicare Select cover in addition to Part A In-Hospital deductible?
• In-Hospital Part A coinsurance for days 61 through 90 in a Medicare Benefit Period.
• In-Hospital Part A coinsurance for days in which Lifetime Reserve days are used.
• Medicare Part A eligible expenses for a Lifetime Maximum of 365 days after all Medicare Part A benefits are exhausted.
• Medicare Part B coinsurance (generally 20% of Medicare’s approved amount).
• Medicare Part B deductible amount applied each calendar year.
• Skilled Nursing Facility stays - the daily coinsurance amount for days 21 to 100 for stays eligible under Medicare.
• Medicare Parts A and B Blood deductible: Charge incurred for the first three pints of unreplaced blood furnished in a calendar year.
• Foreign Travel Emergency.
Medicare Select is a Medicare Supplement product available only to AARP® members who reside within the service area of a hospital which participates in our Medicare Select network. It is a lower cost alternative to Standardized
Medicare Supplement coverage.
Responsibilities of Medicare Select members
To offer the plan at a lower premium, we require that Medicare Select members utilize a participating hospital for all inpatient and outpatient hospital services (except emergency care and services provided when members are outside of their service area).
Hospital responsibilities
Participating hospitals agree to a reduced/waived reimbursement of Medicare’s Part A In-Hospital deductible. Cost savings associated with hospitals’ reduction/waiver of Medicare’s Part A In-Hospital deductible are passed on to Medicare Select members in the form of lower premium cost.
To submit a Medicare Part A or Part B Intermediary claim for a Medicare Select insured, mail a copy of the standard
CMS billing form along with a Medicare Explanation of Benefits or Medicare Remittance Advice to:
AARP® Medicare Select
UnitedHealthcare Claim Division
P.O. Box 740819
Atlanta, GA 30374-0819
Note: Medicare Part B claims billed to a Medicare carrier are, in most cases, received electronically from the
Medicare carrier.
To promote timely processing on all claim submissions, follow standardized Medicare billing practices. Be sure to include the 11-digit AARP® Medicare Select member’s health care ID number on the standard CMS billing form.
What does Medicare Select cover in addition to Part A In-Hospital deductible?
• In-Hospital Part A coinsurance for days 61 through 90 in a Medicare Benefit Period.
• In-Hospital Part A coinsurance for days in which Lifetime Reserve days are used.
• Medicare Part A eligible expenses for a Lifetime Maximum of 365 days after all Medicare Part A benefits are exhausted.
• Medicare Part B coinsurance (generally 20% of Medicare’s approved amount).
• Medicare Part B deductible amount applied each calendar year.
• Skilled Nursing Facility stays - the daily coinsurance amount for days 21 to 100 for stays eligible under Medicare.
• Medicare Parts A and B Blood deductible: Charge incurred for the first three pints of unreplaced blood furnished in a calendar year.
• Foreign Travel Emergency.
Monday, August 8, 2011
Subrogation and Coordination of Benefits (COB) rules
Our benefit plans are subject to subrogation and coordination of benefits (COB) rules.
1. Subrogation — To the extent permitted under applicable law and the applicable benefit plan, we reserve the right to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness.
2. Coordination of Benefits (COB) — COB is administered according to the member’s benefit plan and in
accordance with applicable law. UnitedHealthcare can accept secondary claims electronically. To learn more, go to UnitedHealthcareOnline.com Claims & Payments Electronic Claims Submission (EDI ), contact your EDI vendor, or call EDI support at (800) 842-1109.
Primary Plan --- Plan that pays benefits first --- Benefits under the primary plan will not be reduced due to benefits payable under other plans
Secondary Plan --- Plan will pay benefits after the primary plan --- Benefits under the secondary plan may be reduced due to benefits payable under other primary plans
Tertiary Plan --- Three or more group benefit plans may provide benefits for the same medical expense
Tertiary plans would offset the incurred expenses with the benefits paid by the primary and secondary carriers, and provide benefits for any remaining unreimbursed expenses
Note: When coordinating benefits with Medicare, all COB Types coordinate up to Medicare’s allowed amount when the provider accepts assignment. Medicare Secondary Payer (MSP) rules dictate when Medicare pays secondary.
3. Workers’ Compensation — In cases where an illness or injury is employment-related, workers’ compensation is primary. If notification is received that the workers’ compensation carrier has denied the claim, the provider should submit the claim to UnitedHealthcare, regardless of whether the case is being disputed. It is also helpful to send the other carrier’s denial statement with the claim.
1. Subrogation — To the extent permitted under applicable law and the applicable benefit plan, we reserve the right to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness.
2. Coordination of Benefits (COB) — COB is administered according to the member’s benefit plan and in
accordance with applicable law. UnitedHealthcare can accept secondary claims electronically. To learn more, go to UnitedHealthcareOnline.com Claims & Payments Electronic Claims Submission (EDI ), contact your EDI vendor, or call EDI support at (800) 842-1109.
Primary Plan --- Plan that pays benefits first --- Benefits under the primary plan will not be reduced due to benefits payable under other plans
Secondary Plan --- Plan will pay benefits after the primary plan --- Benefits under the secondary plan may be reduced due to benefits payable under other primary plans
Tertiary Plan --- Three or more group benefit plans may provide benefits for the same medical expense
Tertiary plans would offset the incurred expenses with the benefits paid by the primary and secondary carriers, and provide benefits for any remaining unreimbursed expenses
Note: When coordinating benefits with Medicare, all COB Types coordinate up to Medicare’s allowed amount when the provider accepts assignment. Medicare Secondary Payer (MSP) rules dictate when Medicare pays secondary.
3. Workers’ Compensation — In cases where an illness or injury is employment-related, workers’ compensation is primary. If notification is received that the workers’ compensation carrier has denied the claim, the provider should submit the claim to UnitedHealthcare, regardless of whether the case is being disputed. It is also helpful to send the other carrier’s denial statement with the claim.
Sunday, August 7, 2011
How to Prevent Medical Billing Fraud
Medical billing frauds are mostly related to medical insurances. In the US, such frauds may pertain to Medicare and Medicaid. Many people connected to health care sector may be involved in such frauds. The list of possible fraudsters includes beneficiaries, billing department personnel, recruiters, health care providers, and companies that offer medical services. Quite often invoices are raised for services that were not rendered to the beneficiary. Likewise, fraudulent bills may include medicines that are not prescribed for the beneficiary covered under medical insurance. Beneficiaries claim reimbursement of such bills, which might relate to somebody else's medication. Such inflated bills may also be raised to fleece the beneficiaries.
At times cost of treating ailments that are not covered under any medical insurance, or costs of other services related to health care that do not come under Medicare are recovered by beneficiary through invoices that mention other ailments that are covered. This defeats the purpose of having specific coverage in medical insurance policies and Medicare. Health care facility may raise separate bills for procedures that are already covered under some main billing item. The effect of such unbundling is that the invoices get inflated. Such frauds are obviously felony. They happen with connivance of some medical professionals, and other personnel in billing department of the health care facility. Since legal implications of such frauds are quite serious, health care facility needs to take necessary measures for preventing medical billing frauds.
For starters screening every employee at the time of recruitment is advisable. Background checking of the prospective candidate is a must. It is also necessary to verify the billing certificates produced by the candidate. In addition to this precaution, the health care facility can implement a foolproof system that requires compliance at different stages so that possibilities of medical billing fraud are remote. Somebody from administrative department should be given the responsibility of ensuring regular compliance with the system. This person should also have powers to deal severely with any fraud that may be detected. It is necessary to explain the entire procedure, and various checks integrated in them to every employee. The system should also ensure that an employee can report any abuse by superior without fearing any backlash.
In addition to above measures, the health care facility can ensure that all the rules and regulations stipulated under Health Insurance Portability and Accountability Act (HIPPA) are followed. HIPPA is a US law. It relates to health related information about a patient. It also has provisions relating to patient’s privacy and security of relevant information. HIPPA therefore stipulates that information about a patient such as the patient’s name, medical history, address, etc.. be protected. Passwords that guard such information should be kept a secret so that unscrupulous people do not learn about any patient’s case history. Placing fax machines in places that do not allow general public to access them is another way to prevent medical billing fraud. It is advisable to send encrypted mails relating to the patient rather than sending mails without any security precaution. A confidentiality agreement with severe consequences for breach can be entered into between the facility and the medical billing personnel. Such precautions are necessary even if a third party’s services are being availed for medical billing. Relevant clauses can then be incorporated in the contracts for such services.
At times cost of treating ailments that are not covered under any medical insurance, or costs of other services related to health care that do not come under Medicare are recovered by beneficiary through invoices that mention other ailments that are covered. This defeats the purpose of having specific coverage in medical insurance policies and Medicare. Health care facility may raise separate bills for procedures that are already covered under some main billing item. The effect of such unbundling is that the invoices get inflated. Such frauds are obviously felony. They happen with connivance of some medical professionals, and other personnel in billing department of the health care facility. Since legal implications of such frauds are quite serious, health care facility needs to take necessary measures for preventing medical billing frauds.
For starters screening every employee at the time of recruitment is advisable. Background checking of the prospective candidate is a must. It is also necessary to verify the billing certificates produced by the candidate. In addition to this precaution, the health care facility can implement a foolproof system that requires compliance at different stages so that possibilities of medical billing fraud are remote. Somebody from administrative department should be given the responsibility of ensuring regular compliance with the system. This person should also have powers to deal severely with any fraud that may be detected. It is necessary to explain the entire procedure, and various checks integrated in them to every employee. The system should also ensure that an employee can report any abuse by superior without fearing any backlash.
In addition to above measures, the health care facility can ensure that all the rules and regulations stipulated under Health Insurance Portability and Accountability Act (HIPPA) are followed. HIPPA is a US law. It relates to health related information about a patient. It also has provisions relating to patient’s privacy and security of relevant information. HIPPA therefore stipulates that information about a patient such as the patient’s name, medical history, address, etc.. be protected. Passwords that guard such information should be kept a secret so that unscrupulous people do not learn about any patient’s case history. Placing fax machines in places that do not allow general public to access them is another way to prevent medical billing fraud. It is advisable to send encrypted mails relating to the patient rather than sending mails without any security precaution. A confidentiality agreement with severe consequences for breach can be entered into between the facility and the medical billing personnel. Such precautions are necessary even if a third party’s services are being availed for medical billing. Relevant clauses can then be incorporated in the contracts for such services.
Friday, August 5, 2011
HCPCS - Level 2 Codes
Categories include:
Transportation Services Including Ambulance A0021 - A0999
Medical and Surgical Supplies A4206 - A7509
Administrative, Miscellaneous and Investigational A9150 - A9901
Enteral and Parenteral Therapy B4034- B9999
Temporary codes for use with Outpatient PPS C1010 - C9711
Dental Procedures D0120 - D9999
Durable Medical Equipment E0100 - E2101
Procedures/Professional Services (Temporary) G0001 - G9016
Rehabilitive Services H0001 - H2001
Drugs Administered Other Than Oral Method J0120 - J8999
Chemotherapy Drugs J9000 - J9999
K Codes Assigned to DMERC (Temporary) K0001 - K0597
Orthotic Procedures L0100 - L4398
Prosthetic Procedures L5000 - L9900
Medical Services M0064 - M0301
Pathology and Laboratory Services P2028 - P9615
Q Codes (Temporary) Q0035 - Q9940
Diagnostic Radiology Services R0070 - R0076
Temporary National Codes (non-medicare) S0009 - S9999
National T Codes for State Medicaid Agencies T1000 - T2007
Vision Services V2100 - V2799
Hearing Services V5008 - V5364
Transportation Services Including Ambulance A0021 - A0999
Medical and Surgical Supplies A4206 - A7509
Administrative, Miscellaneous and Investigational A9150 - A9901
Enteral and Parenteral Therapy B4034- B9999
Temporary codes for use with Outpatient PPS C1010 - C9711
Dental Procedures D0120 - D9999
Durable Medical Equipment E0100 - E2101
Procedures/Professional Services (Temporary) G0001 - G9016
Rehabilitive Services H0001 - H2001
Drugs Administered Other Than Oral Method J0120 - J8999
Chemotherapy Drugs J9000 - J9999
K Codes Assigned to DMERC (Temporary) K0001 - K0597
Orthotic Procedures L0100 - L4398
Prosthetic Procedures L5000 - L9900
Medical Services M0064 - M0301
Pathology and Laboratory Services P2028 - P9615
Q Codes (Temporary) Q0035 - Q9940
Diagnostic Radiology Services R0070 - R0076
Temporary National Codes (non-medicare) S0009 - S9999
National T Codes for State Medicaid Agencies T1000 - T2007
Vision Services V2100 - V2799
Hearing Services V5008 - V5364
Wednesday, August 3, 2011
UHC overpayment - How to resolve?
Overpayments
If you identify a claim for which you were overpaid by us, or if we inform you in writing or electronically of an overpaid claim that you do not dispute, you must send us the overpayment within thirty (30) calendar days (or as required by law), from the date of your identification of the overpayment or our request. We may also apply the overpayment against future claim payments to the extent permitted by your agreement with us and applicable law.
All refunds of overpayments in response to overpayment refund requests received from UnitedHealthcare, or one of our contracted recovery vendors, should be sent to the name and address of the entity outlined on the refund request letter. Refunds of any credit balances existing on your records should be sent to:
UnitedHealth Group Recovery Services
P.O. Box 740804
Atlanta, GA 30374-0804
Please include appropriate documentation that outlines the overpayment, including member’s name, health care ID number, date of service and amount paid. If possible, please also include a copy of the remittance advice that corresponds with the payment from UnitedHealthcare. If the refund is due as a result of coordination of benefits with another carrier, please provide a copy of the other carrier’s EOB with the refund.
When we determine that a claim was paid incorrectly, we may make claim reconsiderations without requesting
additional information from the network physician, health care professional, facility or ancillary provider. In the case of an overpayment, we will request a refund at least thirty (30) days prior to implementing a claim adjustment, or as provided by applicable law or contractual agreement. You will see the adjustment on the EOB or Provider Remittance
Advice (PRA). When additional or correct information is needed, we will ask you to provide it.
If you disagree with a claim reconsideration, our request for an overpayment refund or a recovery made to recoup the overpayment, you can appeal the determination (see Claim Appeals section of this Guide).
If you identify a claim for which you were overpaid by us, or if we inform you in writing or electronically of an overpaid claim that you do not dispute, you must send us the overpayment within thirty (30) calendar days (or as required by law), from the date of your identification of the overpayment or our request. We may also apply the overpayment against future claim payments to the extent permitted by your agreement with us and applicable law.
All refunds of overpayments in response to overpayment refund requests received from UnitedHealthcare, or one of our contracted recovery vendors, should be sent to the name and address of the entity outlined on the refund request letter. Refunds of any credit balances existing on your records should be sent to:
UnitedHealth Group Recovery Services
P.O. Box 740804
Atlanta, GA 30374-0804
Please include appropriate documentation that outlines the overpayment, including member’s name, health care ID number, date of service and amount paid. If possible, please also include a copy of the remittance advice that corresponds with the payment from UnitedHealthcare. If the refund is due as a result of coordination of benefits with another carrier, please provide a copy of the other carrier’s EOB with the refund.
When we determine that a claim was paid incorrectly, we may make claim reconsiderations without requesting
additional information from the network physician, health care professional, facility or ancillary provider. In the case of an overpayment, we will request a refund at least thirty (30) days prior to implementing a claim adjustment, or as provided by applicable law or contractual agreement. You will see the adjustment on the EOB or Provider Remittance
Advice (PRA). When additional or correct information is needed, we will ask you to provide it.
If you disagree with a claim reconsideration, our request for an overpayment refund or a recovery made to recoup the overpayment, you can appeal the determination (see Claim Appeals section of this Guide).
Medical Billing
Disclaimer