Medical Billing Question and Answer

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Medical billing process and concept question

 Difference between inclusive and bundled
AS far as I know both are same. Different insurance use different terms.

Difference between authorization and pre-authorization in medical billing?
Both are same however pre-authorization is the one we need to get before providing the service

Difference between 11 & 12 place of service
11 - office (Provider location) visit and 12 - Patient home

Difference between appeal limit and filing limit+medical billing
Filing limit is first time filing and appeal limit is time frame to appeal the claim after denial or low payment.

Difference between billed amount and allowed amount
Difference between fee and allowable in anesthesia billing
Billed amount - What provider billed the insurance.
Allowed amount - What the insurance agree to pay

Difference between claim rejection and denial+medical billing

We can use both word for same meaning. However rejection can't be appeal and denial can be appeal.

Difference between medicare part a and part b
If we need to say in one word
Part A covers hospital and facility billing
Part b covers provider billing

Difference between co 16 and co 50
CO - 16 - Lack of information - check additional denial
CO - 50 - check the CPT and DX combination.

Difference between write off and adjustments in medical billing
Both are same.


Difference between claim and remittance
Claim - Form to use file the information and send it to insurance CMS 1500
Remittance - EOB


Billing question

can a insurance company deny a medical claim due to missing cpt modifier
Ans :Yes they can.

Solution: We need to file appropriate modifier to get paid.
 
can you use a v04.81 as a primary dx for 99213
Ans : No.

Note : It should be used for vaccination and inoculation.
 
can the hospital bill 99213 pos 23
Ans : No.

Note : Place of service 23 could bill only in Emergency room – Hospital.

Can 99213 be billed with 96372 

Ans : No. It will not be paid.
Solution : We have to file with 20553 or any other injection code along with modifier 25 for 99213
Note : 90772 changed to 96372 for 2009

Can 99213 and 99223 billed together

Ans: Two E&M Can not be bill together.

Solution: If the two codes billed, then we need to Write/off for the unpaid CPT. Consultations, critical care, procedures, diagnostic services, and any other non-E/M service cannot be billed as shared visits. Which E/M services can be billed as a shared visit? Most common: New patient visits, established patient visits (follow-up visits), initial hospital visits, subsequent hospital visits, prolonged services, emergency department E/M services.

Can 99291 be billed on a UB 04
Ans : Yes. You can billed on UB 04 form
Solution : UB04 form should be use for facility code 14, 24......

If critical care codes 99291 and 99292 services billed in conjunction with admit type 1. Hospitals are required to use HCPCS code 99291 to report outpatient encounters in which critical care services are furnished. The hospital is required to use HCPCS code 99291 in place of, but not in addition to, a code for a medical visit or for an emergency department service.

Can I bill both CPT codes 85025 and CPT code 36415

Ans : No.

Note : If you have billed CPT 36415 with 85025 they will not be separately reimbursed.


Can 99395 be reimbursed

Ans : 99395 will not be separately reimbursed when submitted with CPT 90772. If the Preventative Maintenance code is billed in any other combination if E&M codes, it will not be payable.

Note :99395 when used for EPSDT services, will be reimbursed at 60% of the Medicare non-facility rate when the recipient is agae 21 or older.
99395 when used not for EPSDT, will be reimbursed at 74% of the Medicare non-facility rate when the recipeint is age 21 or older.

Insurance denial question and answer

Can we bill the patient for a denied pre-existing condition claim

Ans : Yes. But make sure that the patient has secondary coverage; we need to send the entire bill to secondary along with the primary denial. Some carriers may be pay and some may not at that time you can bill the patient.

Note : Pre-existing condition refers to the terms and conditions entered in to between the carrier and the patients/subscribers before the beginning of the contract.  The rejection will usually say that the claim is being denied due to the pre-existing condition.  It would not specify what exactly; the condition is.  So carrier needs to be called to find out the pre-existing condition. Preexisting condition may be for anything.


Claim denial types
There is no particular type in denial however below are the common reason
Claim might be denied for incorrect coding information.
Claim might be denied for incorrect provider information.
Claim might be denied for incorrect coverage information
Claim might be denied for lack of information

 Claim denials by managed care organization plague long-term care providers
Should be file the claim to patient HMO plan


Claim denials for maximum unites per visit
Check your units of the CPT

Claim denied as inclusive with the primary procedure
Some service covered with primary procedure, Hence we needs to taken write off the claim balance after primary CPT paid. However there is chance with resubmit the inclusive procedure with modifier.


Claim denied as services not provided or authorized by designated
File the claim along with appropriate authorization#. If we don’t have authorization# sometimes we can appeal the claim along with necessary medical document.

Claim denied because of incorrect medical coding
Should be file the claim with correct diagnosis (Dx) and CPT

Claim denied because this injury is the liability of the no-fault carrier.
Should be file the claim to patient auto-insurance.

Claim denied by medicaid because primary insurance changed
File the claim to patient primary insurance. If we don’t have patient primary insurance details needs to call the patient and get the insurance information.

Claim denied by medicare for code co-16 what do i do to get this paid?
      We will receive this denial if we have filed the claim with insufficient information. This code co-16 must have additional denials information that informs us what kind of information is missing with claim.


Claim denied due to pre-existing condition
Patient needs to update the medical (medical history) document to insurance and provider also update the medical document to insurance.

Claim denied for CLIA certification#
Should be file the claim with clia certification number. We must file the lab code with clia number.

Claim denied for coordination of benefits
Patient needs to update the COB information to insurance. If patient has more than one insurance, patient need to call the insurance and inform that which insurance is primary and secondary for patient. Patient only can update the COB information to insurance.

Claim denied for maximum benefits reached
File the claim to secondary along with denied EOB. If patient do not have another insurance we can bill the patient.


Claim denied for valid referral
Should be file the claim with valid referral. If we do not have valid referral number, we can request the same from referring doctor and refile the claim with valid referral.


Claim denied no billing code.
Kindly call the insurance and get the reason behind the denials and get the correct CPT

Denied benefits is not covered by the patient's plan.
 We can bill the patient.

Denied insurance claims due to invalid CPT code
     Should be file the claim with valid CPT. For example medicare and HMO plans (Humana, freedom health, AVMED, universal, wellcare, Polk county, PUP,) does not cover the consultation code (99241 to 99245 and 99251 to 99255).

Claim denied reason dates of service over one year from process date are not payable.
    Should be file the claim with in timely filing limit. If you received the denial even filed the claim with in TFL we can appeal the claim with TFL proof. All insurances has separate filing limit.


Claim denial codes and what action needs to be taken
Each denied claim should have valid reason behind the claim denial and needs to take appropriate action from the denials


Claim denial vs claim rejection
Claim denied by insurance and claim rejected by clearing house OR EDI department

Claim denials bundling inclusive
Needs to differentiate the service by using appropriate modifier and Dx else taken write-off the claim balance

 Claim denied primary paid in full
Need to write-off the claim balance.