General / Hot Coding Topics

New Year, New Insurance = New Verification

Question:

How should I file a claim on a patient who has new coverage but has not received an insurance identification card yet? (South Carolina Subscriber)


Answer:

Ideally, when patients call to make appointments, you should have someone in your office confirm their insurance coverage and eligibility, especially if you know the patient is going to have new insurance.  Now is the time of year when benefits verification tends to be most useful. While verification is good practice all year long, January is the time when you’ll see more insurance changes – including payer, benefit, and deductible/copay changes – than at any other time during the year because most employers hold open enrollment in December.

Finding out about insurance changes before the appointment gives you time to check if you are a participating provider with the payer and verify coverage. If the patient doesn’t yet have an identification number with her new insurance company, ask for the name of the insurer and the policy number from the patient, or from the patient’s employer. Then, call the insurer and verify the coverage and the date of eligibility, and get the appropriate information to identify the patient on your claim.

Warning: The date of eligibility is an important question to ask the payer because many employers don’t make health insurance coverage immediately available to new workers. A patient with a new job and new insurance coverage may be in your office for a visit today, but his insurance isn’t effective for two months.

Alternative: Although verifying coverage in advance is preferable, many practices have patients confirm their insurance coverage and note any changes when they check in for their appointments. If you are unable to verify the insurance coverage, or you find that the patient is not eligible for coverage on...

Comments Off on New Year, New Insurance = New Verification
May 5, 2011
Toolkit

Billing Specialist Knowledge Assessment Answer Key

Name: _____________________________________________  Date: _______________

1. A CPT code has ___5_____ digits and an ICD-9-CM code has ___3-5____ digits.

 2. Explain the difference between a CPT code and an ICD-9-CM code.

CPT (Current Procedural Terminology), standardized numeric system (5 digits without modifiers) is used to report WHAT medical services and procedures are done to the patient. 

ICD9 (International Classification of Diseases – Ninth Edition) a Universal coding system is used to describe WHY a service was performed.  Codes range from 3-5 digits.  

3. What is the purpose of a modifier?

To identify in certain circumstances that a service or procedure has been altered by some specific circumstance but it has not changed the basic definition or code  (this is the literal CPT book definition, but anything remotely close to this is acceptable).

4. What are E&M codes?

Evaluation and Management Codes that describe different levels of physician “visits” in various healthcare settings.

5. What does “COB” stand for?   Coordination of Benefits

6. What insurance information do you obtain when the patient contacts our office with new insurance?

Guarantor name, guarantor DOB, guarantor policy and group number, new insurance name, address for claims submission, effective date of new policy, and (if possible) termination date of previous policy.

7.  If the patient has Medicare and Medicaid, which insurance would you bill first?

Medicare would always be billed first.                                              

8. What does HIPAA stand for? And what does it mean to you?        Health Insurance Portability and Accountability Act.

HIPAA designates certain standards and procedures that must be followed to keep secure PHI (protected Health Information). HIPAA also calls for standardization of transaction code sets and various privacy laws (looking for some level of knowledge about the general concept of HIPAA).

9.  How would you handle each of the following EOB rejections?...

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Comments Off on Billing Specialist Knowledge Assessment Answer Key
September 16, 2010
Toolkit

Billing Specialist Knowledge Assessment

Before you hire a biller, you need to make sure he or she is qualified for the position. The following test coupled with a math test will assess whether the candidate will be successful in the role — and an asset to your company.

Name: _____________________________________________  Date: _______________

  1. A CPT code has _______ digits and an ICD-9-CM code has _______ digits
  2. Explain the difference between a CPT code and an ICD-9-CM code
  3. What is the purpose of a modifier?
  4. What are E&M codes?
  5. What does “COB” stand for?  
  6. What insurance information do you obtain when the patient contacts our office with new insurance?
  7. If the patient has Medicare, Tricare and Medicaid, which insurance would you bill first, second, last? 
  8.  Patient is 65; has BCBS through employer w/ 100+ employees and has Medicare Part A only.  Which insurance would you file first?
  9. What does HIPAA stand for? And what does it mean to you? 
  10. What is a CMS 1500 used for?
  11. What is the difference between HCFA and CMS 1500?
  12. How would you handle each of the following EOB rejections?
    • Procedure not a covered benefit
    • Patient not eligible on the date of service
    • Applied to deductible 
    • Bundled Service

 

Multiple Choice

1. A “crossover” claim is:

a. When Medicare forwards a claim electronically to a secondary insurance carrier

b. When duplicate claims are sent and the same claim is returned for more information. (essentially the two claims are “crossing” in the mail)

c. When a claim is sent that has more than one box “crossed out”

d. Sending the claim to the secondary insurance first for administrative purposes, “crossing” the normal procedural policies.

 

2. An EOB is:

a. End of Balance

b....

Comments Off on Billing Specialist Knowledge Assessment
September 16, 2010