Medicare denial

A0    Patient refund amount.
A1    Claim denied charges.
A2    Contractual adjustment.
A3    Medicare Secondary Payer patient liability met.
A4    Medicare Claim PPS Capital Day Outlier Amount.
A5    Medicare Claim PPS Capital Cost Outlier Amount.
A6    Prior Hospitalization or 30-day transfer requirement not met.
A7    Presumptive Payment Adjustment.
A8    Claim denied; ungroupable DRG
B1    Non covered visits.
B2    *Covered visits.
B3    *Covered charges.
B4    Late filing penalty.
B5    Claim/service denied/reduced because coverage guidelines were not met or were exceeded.
B6    This service/procedure is denied/reduced when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
B7    This provider was not certified for this procedure/service on this date of service.
B8    Claim/service not covered/reduced because alternative services were available, and should have been

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Medical billing Terms

Glossary

ADA – American Dental Association: A professional association of dentists committed to the public’s
oral health, ethics, science and professional advancement. http://www.ada.org
AMA – American Medical Association: The American Medical Association helps doctors help
patients by uniting physicians nationwide to work on the most important professional and public
health issues. http://www.ama-assn.org
ANSI – American National Standards Institute: The Institute oversees the creation, promulgation and
use of thousands of norms and guidelines that directly impact businesses in nearly every sector.
http://www.ansi.org
API – Atypical Provider Identifier: Atypical Providers are individuals or organizations that are not
defined as healthcare providers under the National Provider Identifier (NPI) Final Rule. Atypical
providers may supply non-healthcare services such as non-emergency transportation or carpentry.
ARS – Automated Response System: A First Health Services automated system that provides access
to recipient eligibility, provider payments, claim status, prior authorization status, service limits and
prescriber IDs via the phone.
CDT – Current Dental Terminology: Current Dental Terminology (CDT) is a reference manual
published by the American Dental Association that contains a number of useful components, including
the Code on Dental Procedures and Nomenclature (Code), instructions for use of the Code, Questions
and Answers, the ADA Dental Claim Form Completion Instructions, and Tooth Numbering Systems.
http://www.ada.org/ada/prod/catalog/cdt/index.asp
CMS – Centers for Medicare and Medicaid Services: A federal entity that operates to ensure
effective, up-to-date health care coverage and to promote quality care for beneficiaries.
http://www.cms.hhs.gov
CPT – Current Procedural Terminology: CPT® was developed by the American Medical Association

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What is CPT modifiers

Modifiers and their Role in Billing

Modifiers are used to modify payment of a procedure code, assist in determining appropriate coverage, or otherwise identify the detail on the claim. The use of modifiers ensures the appropriate reimbursement by the insurer.

Modifiers are entered in box 24 D on the HCFA-1500 (CMS-1500) claim form or UB 92 (CMS 1450).

For the most current list of modifiers, refer to the current CPT or HCPCS Code book.

Note: The modifiers are updated on a yearly basis, and the tables are supplied to each RPMS site by the IHS Office of Information Technology (OIT). It is the responsibility of each Area IT to install the updated tables.

CPT surgery Modifiers

CPT modifier 62 and 66

Global surgery modifiers

Medical billing help - 2

 Guidelines to Improve Reimbursement

The organizational flow of information and accurate documentation and coding is crucial to processing third party claims.
 
To prevent claims from being rejected, the business process needs to review such areas as:


• inaccurate or lack of coding

• incomplete claims

• lack of supporting documentation

• poor communication with the payer

• not billing for services rendered

The overall reimbursement process is a series of sequential or interconnected but independent steps, starting with the patient’s visit to the facility. The steps involve:

• Assuring that all patients are registered for scheduled or walk-in appointments.

• Obtaining accurate and detailed insurance and demographic information during the registration process.

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Medical billing help

General Billing Guidelines

• All fee schedules need to be reviewed and updated yearly. The Custom Fee Analyzer can be purchased and used as a guide for reviewing the outpatient fee schedule for the facility.

The Analyzer begins with a detailed process on how to review the facility’s fees. It is recommended that once a fee schedule is established by the facility that it is used for all payers. To review codes other than outpatient, use either the HCPCS or Dental Analyzer.

• All diagnoses affecting the current treatment of the patient must be included on the claim forms.

Diagnosis codes (ICD-9) need to be selected with care. All coding must be accurate, precise, and meaningful to guarantee prompt and accurate payment.

• The health care providers will be responsible for providing either the narrative for the diagnosis or in selecting an accurate code that matches his/her written description.

• The coders will code the applicable code and enter all codes into the RPMS system.

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