TOS are used to represent the different types of services and Supplies rendered by the provider.
TOS - Definitions
1 - Medical Care
2 - Surgery
3 - Consultation
4 - Diagnostic X-Ray
5 - Diagnostic Laboratory
6 - Radiation Therapy
7 - Anesthesia
8 - Assistance at Surgery
9 - Other Medical Service
0 - Blood or Packed Red Cells
A - DME
F - Ambulatory Surgical Center
H - Hospice
L - Renal Supplies in the Home
M - Alternate Payment for Maintenance Dialysis
N - Kidney Donor
V - Pneumococcal Vaccine
Y - Second Opinion on Elective Surgery
Z - Third Opinion on Elective Surgery
Tuesday, August 31, 2010
How to create charges?
Creating treatment details: (Charge Creation)
(i) Medical Record Number: This is the number allotted by the physician’s office to track the patient records after his visit.
(ii) Date of Service: The date(s) on which the provider has rendered the service to the patient. It should be entered in the software.
(iii) Provider: Person who provides the healthcare services is known as Provider and his name should be entered in the same software.
(iv) Type of service: It refers the type of treatment has done for the patient. (For e.g., Radiology, Cardiology)
(vi) Name of Clinic/ Facility: It is the place where services are furnished. i.e., in a hospital, clinic, laboratory etc.,
(vii) Referral Authorization Number: This number is issued by the PCP (Primary care Physician) while referring the patient to a specialist or another doctor. managed care plans require such referrals, without which payment may be denied for the services done by the specialist. This referral acts as a kind of a second opinion on the patient’s medical condition. It also helps in keeping the insurance co.’s costs down by filtering the number of patients who really require a specialist’s supervision
(vii) Referring Physician: The doctor who referred the patient to the rendering doctor. referring doctor information is very important if services require referral information, such as in managed care, consults, lab services etc., for diagnostic services such as Radiology (X-Rays), referring doctor is called the ordering
doctor who orders tests.
(viii) Admit Date and Discharge date: if the patient has been admitted to a hospital for treatment then the date on which the patient was admitted and date on which the patient was discharged need to be recorded and communicated to the payer.
(ix) Injury Date: The date on which the first symptoms began for the current illness, injury. This information is used in determining benefits or exclusions for pre- existing condition. In such cases, we need to mention is the injury is work related or due to accident.
(x) Prior Authorization Number: Insurance issues prior authorization number, authorizing the services to be provided if services require prior authorization, the charge sheet will indicate the prior authorization #, Services may not be paid without this number in the claim. This number is an important data element for claim processing.
(xii) Procedure Codes: These are the five digit alphanumeric codes (Common procedural Terminology), which represents the treatment performed for the patient. This might also include the services and supplies.
(xiii) Diagnosis Codes: These are the five digits alphanumeric decimal codes (ICD9CM- International Classification for Diseases-Version- 9 -Clinical modification), which represents the patient illness or condition or disease for which the treatment was rendered or diagnosed as result of the treatment. for e.g.. 486, 719.7, 728.87, v04.89
(xiv) Billed Amount: This is the amount charged by the physician for the particular service rendered to the patient.
(xv) Co payment : Amount that is paid by the patient at the front office before getting treatment. This amount is specific to the type of policy.
(xvi) Units: if the provider performs the same procedure for multiple times, then units should denote it whether it has been done for single time or double time or more.
(xvii) Modifier: Modifiers are the two digits alphanumeric codes that are adopted by the physician to reaffirm to the carrier that the procedure performed was altered or modified due to certain unavoidable circumstances. Below is the list modifiers
(i) Medical Record Number: This is the number allotted by the physician’s office to track the patient records after his visit.
(ii) Date of Service: The date(s) on which the provider has rendered the service to the patient. It should be entered in the software.
(iii) Provider: Person who provides the healthcare services is known as Provider and his name should be entered in the same software.
(iv) Type of service: It refers the type of treatment has done for the patient. (For e.g., Radiology, Cardiology)
(vi) Name of Clinic/ Facility: It is the place where services are furnished. i.e., in a hospital, clinic, laboratory etc.,
(vii) Referral Authorization Number: This number is issued by the PCP (Primary care Physician) while referring the patient to a specialist or another doctor. managed care plans require such referrals, without which payment may be denied for the services done by the specialist. This referral acts as a kind of a second opinion on the patient’s medical condition. It also helps in keeping the insurance co.’s costs down by filtering the number of patients who really require a specialist’s supervision
(vii) Referring Physician: The doctor who referred the patient to the rendering doctor. referring doctor information is very important if services require referral information, such as in managed care, consults, lab services etc., for diagnostic services such as Radiology (X-Rays), referring doctor is called the ordering
doctor who orders tests.
(viii) Admit Date and Discharge date: if the patient has been admitted to a hospital for treatment then the date on which the patient was admitted and date on which the patient was discharged need to be recorded and communicated to the payer.
(ix) Injury Date: The date on which the first symptoms began for the current illness, injury. This information is used in determining benefits or exclusions for pre- existing condition. In such cases, we need to mention is the injury is work related or due to accident.
(x) Prior Authorization Number: Insurance issues prior authorization number, authorizing the services to be provided if services require prior authorization, the charge sheet will indicate the prior authorization #, Services may not be paid without this number in the claim. This number is an important data element for claim processing.
(xii) Procedure Codes: These are the five digit alphanumeric codes (Common procedural Terminology), which represents the treatment performed for the patient. This might also include the services and supplies.
(xiii) Diagnosis Codes: These are the five digits alphanumeric decimal codes (ICD9CM- International Classification for Diseases-Version- 9 -Clinical modification), which represents the patient illness or condition or disease for which the treatment was rendered or diagnosed as result of the treatment. for e.g.. 486, 719.7, 728.87, v04.89
(xiv) Billed Amount: This is the amount charged by the physician for the particular service rendered to the patient.
(xv) Co payment : Amount that is paid by the patient at the front office before getting treatment. This amount is specific to the type of policy.
(xvi) Units: if the provider performs the same procedure for multiple times, then units should denote it whether it has been done for single time or double time or more.
(xvii) Modifier: Modifiers are the two digits alphanumeric codes that are adopted by the physician to reaffirm to the carrier that the procedure performed was altered or modified due to certain unavoidable circumstances. Below is the list modifiers
What are the functions of Charge entry?
Functions of Charge Entry:
(i) Registering the patient’s details from Front office
(ii) Status of the patient (Existing / New patient).
(iii) Cross Verification of Existing Patient’s details (address) with the already existing information.
(i) Registering the patient’s details from Front office
(ii) Status of the patient (Existing / New patient).
(iii) Cross Verification of Existing Patient’s details (address) with the already existing information.
What is Signature on File?
The INSURED and/or PATIENT may authorize the placing of their respective signatures on the medical claim form by the billing medical entity by signing an authorization known as “signature on file”.
What is Accept Assignment?
When a provider agrees to accept the carrier’s determination of the approved as the full fee for the services rendered it is called Accept Assignment. The provider also agrees to collect only the difference between the Medicare approved amount and actual Medicare payment made to the provider for the service. For example, Medicare pays 80% of the approved amount for inpatient psychological services. Therefore, the Medicare beneficiary is responsible for the remaining 20% of the approved amount.
Monday, August 30, 2010
What is Financial Class?
Financial classes are to track categories of patient purposes. It defaults at the patient demographic and ties to the charge. The AR Report will show how much income was generated by each class, as well as the outstanding receivables for each class.
Example of financial class:
M-Medicare
W-Worker Comp
T-Travelers
I-Insurance
S-Self A-Avmed
P-Prucare
D-Medicaid
They are needed to run the different kind of report like:
1.Aged Accounts Receivable Report
2.Detailed Accounts Receivable Report
3.Collection Report
Example of financial class:
M-Medicare
W-Worker Comp
T-Travelers
I-Insurance
S-Self A-Avmed
P-Prucare
D-Medicaid
They are needed to run the different kind of report like:
1.Aged Accounts Receivable Report
2.Detailed Accounts Receivable Report
3.Collection Report
What are the Contents of Demographics entry?
Contents of Demographics:
Patient Details:
Account Number: Generating the patients account number.
Patient Name: Patient name should be entered in the format of Last name, First
name, Middle Initial.
Date of Birth: DOB should be entered in the format of MMDDYYYY format. (For e.g. 21st July 1979 should be entered as 07/21/1979).
Sex: Patient Gender should be mentioned in this field. For e.g., Male/Female/Unknown.
Marital Status: This field should be filled with the details of his/her marital status. For e.g. Single/Married/Divorced/Unknown
SSN(Social Security Number): SSN number is issued by Social Security Administration. It is a 9 digit numerical number issued for all the citizens of US. For e.g., 232-65-3656
(First three number denotes the Area, and the next two number denotes the group and last four digit is the serial number.
Residential Details: Patient complete residential address should be entered. Patient street address should be entered in Address line 1 and if any (APT#, Unit#) should be entered in Address line 2 followed by city name, state and Zip code. Patient Zip code should contain only 5 digit numerics
Telephone Number: Telephone number should contain 10 digits numerics. (For e.g. (403)-243-6546. In this example, first three digit denote area code of the patient and the next three digits represents the group.
Email address: Patient email address should be entered if provided in the demographic sheet.
Spouse Information: If patient is married and spouse information is given, then his/her spouse information should be furnished.
Emergency Contact information: Emergency contact details if any should also be entered while registering demographics.
Employer Details: (a) Name of Employer: Patient employer name should be entered in case of billing WC (Workers Compensation) this field should be entered mandatorily.
(b) Employer address & phone number : Employer’s complete address & phone number should be entered.
(c) Type of business: Patient business or occupation details should be furnished while registering demographic details.
Guarantor Details: (a) Name of Guarantor: Person who is responsible for payment if patient fails to pay is known as guarantor. Name, address and telephone #, SSN should also be entered followed by his name.
Insurance Details:
• Name of the Insurance: Insurance name should be selected from the Insurance master provided in the software.
• Number of Insurance polices: If the patient has more than one Policy coverage, then it should be entered in the order of primary, Secondary and tertiary.
• Policy Id Number: Coverage id should be entered. This Identification number varies based on the insurances. (For e.g., Medicare-9 digit SSN + one Alpha)
• Group Number/Name: Group number or Group name should be entered to identify under which group the patient has enrolled.
• Name of Subscriber: Person who owns the policy is known as subscriber. Under his policy he or his dependents can enjoy the benefits. While registering insurance info policy details should be entered.
• Relation to subscriber: Here you have to mention the relationship to subscriber with the patient like self, spouse, child etc.,
• Effective date & Termination Date of the policy: Start date of policy should be entered. From this effective date only patient can enjoy his benefits on the coverage that he/she has enrolled. termination date should also be furnished while entering demographics details.
Patient Details:
Account Number: Generating the patients account number.
Patient Name: Patient name should be entered in the format of Last name, First
name, Middle Initial.
Date of Birth: DOB should be entered in the format of MMDDYYYY format. (For e.g. 21st July 1979 should be entered as 07/21/1979).
Sex: Patient Gender should be mentioned in this field. For e.g., Male/Female/Unknown.
Marital Status: This field should be filled with the details of his/her marital status. For e.g. Single/Married/Divorced/Unknown
SSN(Social Security Number): SSN number is issued by Social Security Administration. It is a 9 digit numerical number issued for all the citizens of US. For e.g., 232-65-3656
(First three number denotes the Area, and the next two number denotes the group and last four digit is the serial number.
Residential Details: Patient complete residential address should be entered. Patient street address should be entered in Address line 1 and if any (APT#, Unit#) should be entered in Address line 2 followed by city name, state and Zip code. Patient Zip code should contain only 5 digit numerics
Telephone Number: Telephone number should contain 10 digits numerics. (For e.g. (403)-243-6546. In this example, first three digit denote area code of the patient and the next three digits represents the group.
Email address: Patient email address should be entered if provided in the demographic sheet.
Spouse Information: If patient is married and spouse information is given, then his/her spouse information should be furnished.
Emergency Contact information: Emergency contact details if any should also be entered while registering demographics.
Employer Details: (a) Name of Employer: Patient employer name should be entered in case of billing WC (Workers Compensation) this field should be entered mandatorily.
(b) Employer address & phone number : Employer’s complete address & phone number should be entered.
(c) Type of business: Patient business or occupation details should be furnished while registering demographic details.
Guarantor Details: (a) Name of Guarantor: Person who is responsible for payment if patient fails to pay is known as guarantor. Name, address and telephone #, SSN should also be entered followed by his name.
Insurance Details:
• Name of the Insurance: Insurance name should be selected from the Insurance master provided in the software.
• Number of Insurance polices: If the patient has more than one Policy coverage, then it should be entered in the order of primary, Secondary and tertiary.
• Policy Id Number: Coverage id should be entered. This Identification number varies based on the insurances. (For e.g., Medicare-9 digit SSN + one Alpha)
• Group Number/Name: Group number or Group name should be entered to identify under which group the patient has enrolled.
• Name of Subscriber: Person who owns the policy is known as subscriber. Under his policy he or his dependents can enjoy the benefits. While registering insurance info policy details should be entered.
• Relation to subscriber: Here you have to mention the relationship to subscriber with the patient like self, spouse, child etc.,
• Effective date & Termination Date of the policy: Start date of policy should be entered. From this effective date only patient can enjoy his benefits on the coverage that he/she has enrolled. termination date should also be furnished while entering demographics details.
What are the documents submitted by a New patient at the Front Office?
Documents submitted by a New patient at the Front Office:
(a) Patient Demographic details
(b) Guarantor Details
(c) Patient & Guarantor Employer details
(d) Assignment of Benefits
(e) Release of Information
(f) Promissory Note
a) Patient Demographic Detail: The patient details will get registered in buck slip at the front office.
b) Guarantor Details: The details of the person who is going to accompany with the patient will also be registered at the front office.
c) Employer Information: Employer details of both patient and guarantor will also be collected at the front office.
d) AOB: (Assignment of Benefits): The Patient or guardian signs the assignment of benefits form so that the physician or medical provider will receive the insurance payment directly. This form will also be submitted at the front office.
e) ROI (Release of Information): The patient authorizes the provider to release his personal and medical information for the purpose of medical billing.
f) Promissory Note: Is a notice to maintain patient goodwill with extended payment plans.
(a) Patient Demographic details
(b) Guarantor Details
(c) Patient & Guarantor Employer details
(d) Assignment of Benefits
(e) Release of Information
(f) Promissory Note
a) Patient Demographic Detail: The patient details will get registered in buck slip at the front office.
b) Guarantor Details: The details of the person who is going to accompany with the patient will also be registered at the front office.
c) Employer Information: Employer details of both patient and guarantor will also be collected at the front office.
d) AOB: (Assignment of Benefits): The Patient or guardian signs the assignment of benefits form so that the physician or medical provider will receive the insurance payment directly. This form will also be submitted at the front office.
e) ROI (Release of Information): The patient authorizes the provider to release his personal and medical information for the purpose of medical billing.
f) Promissory Note: Is a notice to maintain patient goodwill with extended payment plans.
Anesthesia Code Modifiers
AA - Anesthesia services personally performed by anesthesiologist - Distinct fee schedule amount. Affects payment.
AD - Medical supervision by a physician: More than 4 concurrent anesthesia procedures -. Distinct fee schedule amount. Affects payment.
G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
G9 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
QK - Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by a physician or non-supervised CRNA.
QS - Monitored anesthesia care - No effect on payment. For informational purposes only. Must be used in conjunction with a pricing anesthesia modifier.
QX - CRNA service with medical direction by physician - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by physician or non-supervised CRNA.
QY - Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.
QZ - CRNA service without medical direction by a physician - No effect on payment. Payment is equal to the amount that would have been allowed if personally performed by a physician.
23 - Unusual anesthesia - Used to report a procedure which usually requires either no anesthesia or local anesthesia; however, because of unusual circumstances must be done under general anesthesia.Coverage /payment will be determined on a "by-report" basis.
47 - Anesthesia by surgeon - Used to report regional or general anesthesia provided by the surgeon (Not covered by Medicare).
AD - Medical supervision by a physician: More than 4 concurrent anesthesia procedures -. Distinct fee schedule amount. Affects payment.
G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
G9 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
QK - Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by a physician or non-supervised CRNA.
QS - Monitored anesthesia care - No effect on payment. For informational purposes only. Must be used in conjunction with a pricing anesthesia modifier.
QX - CRNA service with medical direction by physician - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by physician or non-supervised CRNA.
QY - Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.
QZ - CRNA service without medical direction by a physician - No effect on payment. Payment is equal to the amount that would have been allowed if personally performed by a physician.
23 - Unusual anesthesia - Used to report a procedure which usually requires either no anesthesia or local anesthesia; however, because of unusual circumstances must be done under general anesthesia.Coverage /payment will be determined on a "by-report" basis.
47 - Anesthesia by surgeon - Used to report regional or general anesthesia provided by the surgeon (Not covered by Medicare).
What are HCPCS Modifiers?
HCPCS code modifiers accompany HCPCS codes (e.g., CPT, level II) to provide additional information regarding the product or service identified. Modifiers are used when the information provided by a HCPCS code descriptor needs to be supplement to identify specific circumstances that may apply to an item or service.
What are HCPC codes?
Healthcare Common Procedure Coding System (HCPCS, pronounced as “hick-picks”) presents the procedure/service codes reference developed by CMS. HCPCS furnishes health care providers and suppliers with a standardized language for reporting processional services procedures, supplies, and equipment not included in CPT. These HCPCS codes are also five characters in length but begin with the letters A – V followed by four numbers. Most state Medicaid programs also use HCPCS.
List the ICD9 codes
The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems.
ICD-9 codes 001-139: Infectious and parasitic diseases
ICD-9 codes 140-239: Neoplasms
ICD-9 codes 240-279: Endocrine, nutritional and metabolic diseases, and immunity disorders
ICD-9 codes 280-289: Diseases of the blood and blood-forming organs
ICD-9 codes 290-319: Mental disorders
ICD-9 codes 320-359: Diseases of the nervous system
ICD-9 codes 360-389: Diseases of the sense organs
ICD-9 codes 390-459: Diseases of the circulatory system
ICD-9 codes 460-519: Diseases of the respiratory system
ICD-9 codes 520-579: Diseases of the digestive system
ICD-9 codes 580-629: Diseases of the genitourinary system
ICD-9 codes 630-676: Complications of pregnancy, childbirth, and the puerperium
ICD-9 codes 680-709: Diseases of the skin and subcutaneous tissue
ICD-9 codes 710-739: Diseases of the musculoskeletal system and connective tissue
ICD-9 codes 740-759: Congenital anomalies
ICD-9 codes 760-779: Certain conditions originating in the perinatal period
ICD-9 codes 780-799: Symptoms, signs, and ill-defined conditions
ICD-9 codes 800-999: Injury and poisoning
ICD-9 codes E and V codes: External causes of injury and supplemental classification
E Code ranges from E800 – E999.
V Code ranges from V01 – V85
ICD-9 codes 001-139: Infectious and parasitic diseases
ICD-9 codes 140-239: Neoplasms
ICD-9 codes 240-279: Endocrine, nutritional and metabolic diseases, and immunity disorders
ICD-9 codes 280-289: Diseases of the blood and blood-forming organs
ICD-9 codes 290-319: Mental disorders
ICD-9 codes 320-359: Diseases of the nervous system
ICD-9 codes 360-389: Diseases of the sense organs
ICD-9 codes 390-459: Diseases of the circulatory system
ICD-9 codes 460-519: Diseases of the respiratory system
ICD-9 codes 520-579: Diseases of the digestive system
ICD-9 codes 580-629: Diseases of the genitourinary system
ICD-9 codes 630-676: Complications of pregnancy, childbirth, and the puerperium
ICD-9 codes 680-709: Diseases of the skin and subcutaneous tissue
ICD-9 codes 710-739: Diseases of the musculoskeletal system and connective tissue
ICD-9 codes 740-759: Congenital anomalies
ICD-9 codes 760-779: Certain conditions originating in the perinatal period
ICD-9 codes 780-799: Symptoms, signs, and ill-defined conditions
ICD-9 codes 800-999: Injury and poisoning
ICD-9 codes E and V codes: External causes of injury and supplemental classification
E Code ranges from E800 – E999.
V Code ranges from V01 – V85
What are CPT Modifiers?
CPT modifiers clarify services and procedures performed by providers, and while the CPT code and description remains unchanged, modifiers indicate that the description of the service or procedure performed has been altered. CPT modifiers are reported as 2-digit numeric codes added to the 5-digit CPT code.
List the CPT Sections
Description Range of codes
Evaluation & Management 99200 – 99499
Anesthesiology 00100 – 01999
Surgery 10000 – 69999
Radiology 70000 – 79999
Pathology & Laboratory 80000 – 89999
Medicine 90000 – 99199
Evaluation & Management 99200 – 99499
Anesthesiology 00100 – 01999
Surgery 10000 – 69999
Radiology 70000 – 79999
Pathology & Laboratory 80000 – 89999
Medicine 90000 – 99199
List the categories of CPT codes
Category I Codes: Procedures/services identifies by a five-digit codes
Category II Codes: contain "performance measurements"
Category III Codes: contain "emerging technology"
Category II Codes: contain "performance measurements"
Category III Codes: contain "emerging technology"
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