Medical Billing & Coding For Dummies Cheat Sheet

A clean medical claim is one that has no mistakes and can be processed without additional information from the provider or a third party. It’s correct from top to bottom. A clean medical claim meets the following criteria:

• The healthcare provider is licensed to practice on the date of service and is not under investigation for fraud.
• Every procedure code has a supporting diagnosis code, which eliminates any questions about medical necessity. In addition, the form includes no expired or deleted codes.
• The patient’s coverage was in effect on the date of service, and the patient’s insurance covers the service provided.
• The claim form includes all the required information (patient name, address, date of birth, identification number, and group number) in the correct fields.
• The form correctly identifies the payer and includes the right payer identification number and payer mailing address.
• The claim is submitted on time.

The world of medical billing and coding is like one big bowl of alphabet soup because using abbreviations and acronyms in medical records saves time. Each medical office will have its own most frequently used acronyms based on its area of expertise; but here are some of the most common abbreviations and acronyms used in all medical offices:

• CMS (Centers for Medicare & Medicaid Services): The division of the United States Department of Health and Human Services that administers Medicare, Medicaid, and the Children’s Health Insurance Program.
• EDI (electronic data interchange): The electronic systems that carry claims to a central clearinghouse for distribution to individual carriers.
• RA (remittance advice): A document, issued by the insurance company in response to a claim submission, that outlines what services are covered (or not) and at what level of reimbursement. Each payer has its own RA form.
• HIPAA (Health Insurance Portability and Accountability Act): The law, sometimes called the Privacy rule, outlining how certain entities like health plans or clearinghouses can use or disclose personal health information. Under HIPAA, patients must be allowed access to their medical records.
• HMO (health maintenance organization): A health management plan that requires the patient use a primary care physician who acts as a “gatekeeper.” In HMOs, patients much seek treatment from the primary physician first, who, if she feels the situation warrants it, can refer the patient to a specialist within the network.
• INN (in-network): A provider who has a contract with either the insurance company or the network with whom the payer participates.
• OON (out-of-network): An out-of-network provider is one who does not have a contract with the patient’s insurance company.
• POS (point of service): A health insurance plan that offers the low cost of HMOs if the patient sees only network providers.
• PPO (preferred provider organization): A health management plan that allows patients to visit any providers contracted with their insurance companies. If the patient visits a non-contracted provider, the claim is considered out-of-network.
• WC (workers’ compensation):S. Department of Labor program that insures employees who are injured at work.

Insurance companies (payers) offer various levels of coverage to their members, and as the medical biller/coder, you must be able to navigate payer contracts to gather the information you need to prepare and follow-up on claims. Many payers or networks have standardized contracts that they offer to healthcare providers. A well-defined contract does the following:

• Defines the number of days after the encounter that the provider has to submit the claim. This is called timely filing.
• Specifies how many days after receipt of the claim the payer has to make payment.
• Specifies which of the payer plans are included, the frequency of services that it will cover (for certain procedures), and the type of claim that providers must submit.
• Identifies special circumstances, such as how unlisted procedures will be reimbursed, which procedures are carved out of the fee schedule, the number of procedures that the payer will pay per encounter, and how to apply the multiple procedure discount.
• Identifies the appeals process.
• Identifies cost-intensive supplies or procedures (such as implants, screws, anchors, plates, rods, and so on) that may need to be paid.

As a biller/coder, make sure you’re familiar with the contract specifics, and if you have any questions, talk to more experienced billers and coders in your office or call the payer directly for clarification.