The World of Computer Software/World_Of_Computer_Software-02-387-Vol-3of3.iso/p/pcm_hlth.exe/APPLICAT.TXT

Text File | 1993-03-27 | 9KB | 140 lines

                   PCM MEDICAL BILLING INFORMATION APPLICATION      3/26/93
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     NOTE: This APPLICATION contains a sample of medical billing
           information put together by PC MANAGEMENT for use by
           users of this bulletin board. It reflects in
           principle the Medicare billing scheme for Physician
           HCPCS service data.

           PC MANAGEMENT is using  data of this type in
           REFERENCE APPLICATIONS of medical billing information
           for clients. The applications  reflect the "Practice Specific"
           procedures, codes, regulatory comments, modifiers, and
           other data essential to accurate coding and timely processing
           of insurance claims. Claims rejections are minimized and
           claim amounts are accurately maximized.
           Medical SPECIALTY Billing and Reimbursement services are available
           on a fee for service, BBS subscription, and/or project charge.
     NOTE: Contact Patt @ PCM's HEALTHCARE DATA BBS(HealthCare SYSOP)
           for Specialty information. Voice contact @ [phone]
           is available Monday - Friday from 9a.m. to 5p.m. eastern
           standard time. (BBS [phone] | 2400,N,8,1 )
     NOTE: Custom Applications for a full range of physician services can be
           provided to meet your needs in dBase or WordPerfect format; or to
           match your special needs.

     NOTE: If you are new to Medical billing, you may find this APPLICATION
           useful as a tutorial. The APPLICATION is outlined to provide
           medical billing information in non medical terminology.
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INTRODUCTION
The basic foundation to medical billing consist of:
1.The "PROCEDURE CODE" which defines the medical service rendered.
     The most commonly used procedure coding is the three level
     Health Care Procedure Coding System (HCPCS).
             a.Level I. the American Medical Association numeric CPT codes
             which describe various physician and laboratory procedures.
             b.Level II.the Health Care Financing Administration alpha-numeric
             codes listing non-physician (and a few physician) services, i.e.
             supplies, durable equipment, ambulance services, etc.
             c.Level III. the carrier(in Florida, Blue Cross & Blue Shield)
             alpha-numeric codes which describe services not listed in level I
             or level II
2.The "DIAGNOSIS CODE" which defines the reason for the service rendered.
     The most commonly used diagnosis coding system is The U.S. Department of
     Health and Human Services, International Classification of Diseases, 9th
     Revision, Clinical Modification (ICD-9-CM).
3.The "FEE" establishes the charge for the medical service rendered.
     The most commonly used source for basis of establishing the fee
     structure for physician services is the Resource Base Relative Value
     system (RBRVs)as  required by section 6102(a) of the Omnibus Budget
     Reconciliation Act of 1989 as amended by the Omnibus Budget
     Reconciliation Act of 1990 with a revised Medical Economic Index(MEI) to
     reflect year-to-year price changes affecting the cost of providing
     physicians' services. The RBRVS uses three elements to determine the
     "value" of a procedure 1. the work involved, 2. the cost of the medical
     practice as it relates to the procedure,and 3. the cost of mal-practice
     insurance as it relates to the procedure.  These three elements are then
     adjusted according the  geographic area, or cost of living concept. (see
     example A.)
4.The "INSURANCE FORM"; document used to transmit, by paper or computer the
     medical billing data to the insurance carrier for reimbursement.
     The HCFA 1500 form, the most commonly used data form to submit billing
     information to a the carrier or insurance company for reimbursement to
     the provider and beneficiary. This format is utilized for the paper
     claim submission as well as the Electronic Medical Claims (EMC).
5.The "RULES and REGS" with which the payor governs the provider for the
     purpose of billing and reimbursement.
     The most commonly used source for establishing the fee structure for
     physician services is the Resource Base Relative Value system (RBRVs)as
     required by section 6102(a) of the Omnibus Budget Reconciliation Act of
     1989 as amended by the Omnibus Budget Reconciliation Act of 1990 with a
     revised Medical Economic Index(MEI) to reflect year-to-year price
     changes affecting the cost of providing physicians' services.
     The most commonly used source of rules and regs for medical billing are
     the Code of the Federal Register(CFR) 42 covering Medicare and Medicaid,
     and the payor carriers' manual. These publications outline utilization,
     and other regulatory information specific to medical specialty billing
     procedure and diagnosis coding.


APPLICATION
     For the purpose of brevity, this Application will address the medical
billing as it applies to Medicare.  Usually Medicare is the most restrictive
regarding rules & regs, and the most studied regarding Resource Base Relative
Value (RBRV).  The RBRV established a set value for each procedure adjusted by
the Geographic Practice Cost Index (GPCI) to reflect to value for the
procedure by each geographic area. The next step was to use a conversion
factor(CF) amount to convert the value to an actual dollar amount. The CF
adjusted yearly according the MEI.

     Although "documentation' is the key to all good medical billing, this
APPLICATION will concentrate on the mechanics of billing, assuming the
necessary documentation has been established.  The first area of established
medical billing documentation should be verification of entitlement or
coverage of the beneficary of the medical service.

     Step 1; the procedure code for the service rendered is selected, and
     Step 2; the diagnosis for the procedure rendered is selected...

These two steps are known as "coding". The most common rule regarding coding
is that the diagnosis fit (be relative to) the procedure being rendered.  Some
procedures are limited in the range of diagnoses that are allowed for the
procedure. Some procedures are limited in the number of times the service can
be rendered by the physician in a given period of time.  The rules and regs
specific to the Medicare billing are established through the carrier for each
locality and the restrictions on the billing of these procedures are listed in
the carrier publication.  In the state of Florida, the carrier(Blue Cross Blue
Shield) publication is the "UPDATE". All providers are subscribers to UPDATE.
service. The initial rules and regulations regarding medical billing are
established by the Health Care Financing Administration and published in
carrier manuals as well as the Code of the Federal Regulations (CF 42).
     Physician services are divided into two basic categories, (1) Surgical
and (2) Nonsurgical.  Certain guidelines apply to Surgical procedures as it
relates to reimbursement such as:

                Global Surgery Post-Op
                Multiple Surgery
                Bilateral Surgery
                Multiple Endoscopic Procedures
                Co-Surgery
                Dermatological Surgery
                Site of Service Procedures

     Medical billing begins with a physician service represented by a
procedure code; a specific diagnosis represented by a diagnosis code; and
a fee or charge established by the relative value of the procedure codes. This
information is submitted in a format (claim) to the insurance or entitlement
carrier for reimbursement (payment) to the provider or beneficiary of the
medical service. The reimbursement is calculated according to an established
set of rules and regulations initially set forth by the Health Care Financing
Administration as interpreted by the carrie processing the "claim".
     This application is just an outline of the medical billing process.
Medical billing for reimbursement has become very technical.  The medical
biller must be cognizant of ever changing rules and regs.  This is especially
true in this current age of the  "health care crisis". [pec/PCM]