Medical Billing Salary Range

Depending on the education qualification, the hourly rate varies from $12-$15. Another most important factor that affects billing pay is how long someone has worked in the field. Medical specialist with experience of 1 year earns around $12 per hour. Those who have more experience in billing earn up to $16 per hour. However, the geographic location also plays a role in pay scale. 

For instance, areas where cost of living is high, the pay will be more. Billers who work in New York City, Houston, Chicago and California are able to pull a good amount of salary. Work locations such as hospital, billing company or private practice will also affect the salary. Since there are lots of factors which affect the salary of billing, it is really not easy to predict the pay scale. Studies have shown that 50% of people earned around $35,000-$45,000 annually.

Most of the medical Billers are paid hourly, rather than annually. While Biller who is experienced can earn around $40,000 a year as an independent contractor working from home, a billing and coding specialist who runs his own firm can earn $100,000 a year. However, people who are searching for home based job should be very careful. There is lots of fraud going on in this field. 

These spammers charge hundred to thousand dollars and in exchange they claim they will help to get a placement in billing. They also promise that medical billing job can earn a substantial amount of money and no experience required. But in reality, those who paid to get a job end up with no job, no money. Billing is a very competitive field, so without experience or training in medical billing field, it is almost impossible to get a job.

Medical Billing Salary Range

Depending on the education qualification, the hourly rate varies from $12-$15. Another most important factor that affects billing pay is how long someone has worked in the field. Medical specialist with experience of 1 year earns around $12 per hour. Those who have more experience in billing earn up to $16 per hour. 

However, the geographic location also plays a role in pay scale. For instance, areas where cost of living is high, the pay will be more. Billers who work in New York City, Houston, Chicago and California are able to pull a good amount of salary. Work locations such as hospital, billing company or private practice will also affect the salary. Since there are lots of factors which affect the salary of billing, it is really not easy to predict the pay scale. Studies have shown that 50% of people earned around $35,000-$45,000 annually.

Most of the medical Billers are paid hourly, rather than annually. While Biller who is experienced can earn around $40,000 a year as an independent contractor working from home, a billing and coding specialist who runs his own firm can earn $100,000 a year. However, people who are searching for home based job should be very careful. 

There is lots of fraud going on in this field. These spammers charge hundred to thousand dollars and in exchange they claim they will help to get a placement in billing. They also promise that medical billing job can earn a substantial amount of money and no experience required. But in reality, those who paid to get a job end up with no job, no money. Billing is a very competitive field, so without experience or training in medical billing field, it is almost impossible to get a job.

Selecting Medical Billing Software - 10 things to consider

1. The first step is to evaluate your needs. And when evaluating different systems look for a package that goes one step ahead of billing. Choose a medical practice management system MPP. This will handle considerably more that just medical billing.

2. Determine whether the system handles electronic transmission of claims, direct billing for patients, co-pays, co-insurance, and expenses not covered by insurance.

3. Weigh the pros and cons of different medical billing systems and ask to see a system in operations. Always check out the references yourself.

4. Look for a medical billing management system that is user friendly. When a vendor demonstrates get your office staff to be present. This way you will be able to check how the software functions. Any software must be easy to use to be productive. The system should be fool proof.

5. Ask whether the medical billing software is a traditional system, one that will work on your office computers or an application service provider system (ASP), one that will process data at the software company’s data center.

6. Always get quotes from at least three medical billing software providers.

7. Ask whether they are offering an evaluation period or trial. This will enable you to know in actuality whether the system works or not.

8. Find out about training your office people, up-gradation of system, and whether the software is compatible with your office computer systems

.9. Find out whether the system will handle appointment scheduling, maintenance of records and so on apart from electronic medical records, SOAP notes, and billing. Choose a system that is comprehensive.

10. An ideal Medical Billing software system must include aspects like payment posting, reconciliation; follow up, secondary submission, and patient billing.Choose a transparent billing system that enhances your office efficiency. Install a system that you can use not one that will lead to frustration and problems.Medical billing systems must free your time and that of your office staff not make you run in circles. Choose a system with care.

How Can I Prepare for a Job as a Medical Biller?

While training courses exist for medical billing jobs, going through one is not required to become a biller. In fact, medical billing does not require any prior knowledge or training, but landing a job without any knowledge of the field will be difficult. Before paying for a training course, look at the value of the time and money that you will commit. 

Overall, medical billing is a basic skill to understand. Nothing advanced is required, and spending 12 or 18 months, as some programs have you do, is unnecessary. Opt for something that will teach you the ins and outs of the job in a few weeks, and you will be just as prepared as someone who spends months learning what the ob requires

Medical Billing: A Great Home Business

If you’re looking for a promising home business, and you’re organized, good with numbers and have some marketing ideas, you can start a medical billing business from your home office. You can make it a full-time or part-time venture.

With a medical billing business, you submit claims for a health provider’s office and bill patients for their portion. You will follow up on unpaid insurance claims, write appeals when needed and possibly do patient collections.

You will need some training for this business, because you will need to become familiar with some basic medical language, as well as diagnostic codes and procedure codes. You will also need to know how an insurance claim works. 

You may be able to get this training informally, by finding another small medical business billing company and asking for an apprenticeship. If you find this sort of opportunity, it’s a good chance the person helping you is looking for someone to handle their overflow work. You can also find medical billing courses at your community college or through an online home study course.

Once you’re ready to start your business, find a space in your home for your office. This is not a business you can do from your kitchen table, simply because you will be dealing with confidential information. You will have access to patient names and the diagnostic codes tied to their names. You’ll need a separate room that be locked off from the rest of the house. And you’ll need locked file cabinets inside your office. In addition, you will need to make the computer you work on password protected.

Buying your own medical billing software will be your next step and probably your largest expense. Don’t get trapped into buying one that has more bells and whistles than you need, but make sure the one you do purchase can grow with your business. Research the programs available, ask for demos and ask other medical billing specialists what they like and dislike about their programs. Make sure the software you choose has technical support that is available long after your initial purchase.

The only thing left to do is market your new business. You can start with your family doctors. They may not need your services, but will probably be happy to pass your name on to their friends. Don’t forget other medical billing companies. They will get inquires about services, and if they’re busy, will probably be more than happy to refer you.

Things are changed lot now and getting complicated day by hence working from Home is not easy anymore.

Medical Billing Outsourcing & Services and process involved in Medical Billing

Question need to ask when Medical Billing Outsourcing

1. Check with their referral and how long they are doing this business.

2. Are they HIPAA compliance

3. Where they are doing their work. If possible just visit there.

4. Data security.

5. Compare the price with others.

6. what are the reports they will provide

7. Your specialty wise question

8. Their software skills.

Advantage of Medical Billing Outsource

Medical Billing Company helps you in managing all your billing requirements proficiently. By choosing right medical billing company, you can get benefit such as improved financial strength.

Medical Billing task is very tedious and time consuming. However, billing must require more accuracy and special attention to strengthen the financial condition of clinical or hospital. You can do this task at own or assign to clinical staff but you have to be pleased with low patients satisfaction. Medical billing company can help you in supportive task. By efficient medical service, you will get highly satisfied patients.

Procedure Codes, Revenue Codes, and Modifiers

The (837) Professional and Institutional electronic claims and the paper claims have been modified to accept up to four Procedure Code Modifiers

Revenue Code  -  Procedure Code - Description

821 - 90935 Hemodialysis procedure with single physician evaluation. Limited to 156 units per year.

821 - 90937 Hemodialysis procedure requiring repeated evaluations with or without substantial revision of dialysis prescription. Limited to 156 units per year.

831 -841 - 851 - 90945 Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) with single physician evaluation.

831 841 851 -  90947 Dialysis procedure other than hemodialysis (e. g. peritoneal, hemofiltration) requiring repeated evaluations with or without substantial revision of dialysis prescription.

831 851 841-  90993 Dialysis training, patient, including helper. Limited to 12 units per lifetime.250- Q4081 Injection, epogen 250-  J0882 Injection, darbepoetin alfa

Hemodialysis

The following table lists Hemodialysis tests and frequency of coverage:

Frequency                  Covered Tests
Per treatment    All hematocrit and clotting time tests furnished incidentally to dialysis treatments.
Weekly             Prothrombin time for patients on anticoagulant therapy; serum creatinine, BUN.
Monthly            Alkaline Phosphates LDH Serum Biocarbonate Serum Calcium
                        Serum Chloride
                        Serum Phosphorous
                        Serum Potassium
                        SGOT
                        Total Protein

All laboratory testing sites providing services to Medicaid recipients, either directly by provider or through contract, must be certified by Clinical Laboratory Improvement Amendments (CLIA) that they provide the required level of complexity for testing. Providers are responsible for assuring

Medicaid that they strictly adhere to all CLIA regulations and for providing Medicaid waiver certification numbers as applicable. Laboratories that do not meet CLIA certification standards are not eligible for reimbursement for laboratory services from Medicaid.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

11X, 12X, 13X, 85X

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

procedure/HCPCS Codes 33240©

Insert pulse generator 33241©

Remove pulse generator 33243©

Remove eltrd/thoracotomy 33244©

Remove eltrd, transven 33249©

Eltrd/insert pace-defib

Effective for services furnished on or after January 1, 2012, the American Medical Association (AMA) changed the descriptor for procedure  code 33249 to read “Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.”

This has necessitated the removal of HCPCS code C1882 (Cardioverter-defibrillator, other than single or dual chamber (implantable)) from the list of those device codes required to be billed with procedure code 33249 on the procedure-to-device edit list, since this link is no longer clinically appropriate. CMS is making this change retroactive to January 1, 2012.

Q: Is prior authorization required?

A: Yes, procedure  codes 33230, 33231, 33240, 33249, 33262, 33263 and 33264 are included in the Cardiology Prior Authorization Program

Problem of In House Processing of Medical Claims

Medical claims are generally very complex and have long extended details. While processing medical claims, one has to be highly critical and do efficient follow-up in order to get results. The process requires a lot of time and effort. And even after all this, there can be cases where files get lost or a small error can ruin the entire lot and everything has to be re-submitted again. Usually practice staff can be held up with lot of current work rather than submitting the claim and resubmitting the corrected claim hence it will lead to time delay on payment flow and it will affect all the relationship with in the practice. Even cost wise is also not effective when compare to outsourcing.

Medical Billing specialist Professional

If a person is computer literate he is a fit enough candidate to take up the profession of medical billing and medical coding. However he will need to be trained and be aware of a lot of new information before he can start working effectively. He has to learn about the medical billing software and must be familiar with and master the various commands used while working with it.

Who are medical coders and how is it related to medical billing? Medical billing is a sub specialty of medical coding. Medical coding is the first step in the billing process. All patient records are maintained using the ICD-9 index system so that it is compliant with the federal rules.

Medical Billing Specialist.

The person who is doing this process will be called Medical billing specialist.

Medical billing Specialist is the one who is handling the below process and having well knowledge in each and every process.

* Insurance verification process

* Patient demographic and charge entry process.

* Submitting the claims by electronic as well as paper method. Tracking various claim submission report.

* Payments posting process for insurance as well as patient.

* Denial management.

* Insurance followup management.

* Insurance appeal process.

* Handling patient billing inquiries.

* Patient statement process.

* Preparing monthly reports such as revenue report and account receivable report and as per the provider requirement.

Problem in Medical Billing

•Inaccurate or lack of coding

• Incomplete claims

• Lack of supporting documentation

• Poor communication with the payer

• Not billing for services rendered

* Not being follow up AR balance claims

Claim submission Process & Payment Posting Process

Claim submission Process

The next step after demographics and charge entry is claim generation. Claims may be paper claims or electronic claims. There are various types of forms for paper claims. The most widely used form is Health Care Finance Admin-1500 designed by the Health Care Financing Administration.

Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through internet . The claim information is directly loaded into the insurance company's computer system or to the clearing house.

Insurance verification & Demo and Charge entry process

Insurance verification

Process started from here and usually front desk people are doing this process. Its a process of verifying the patients insurance details by calling insurance or through online verification. If this department works well, we could resolve more problem. We have to do this even before patient appointment.

Medical coding

Medical coding is the process of converting Medical terms to numeric code and it required Medical knowledge skills.

Medical billing is the process of submitting the claims and get paid behalf of provider.

Medical Billing

The physician doesn’t get paid for his services immediately after they are rendered. Majority of the patients have insurance coverage and details of such coverage are provided to the physician before treatment. It is the responsibility of the physician to submit claims to the insurance company and get paid for his services. Submitting Claims and getting paid is a lengthy process and involves a lot of rules and regulatory systems and is very complicated. The physician needs to adhere to all these rules before submitting claims. This is the concept of Medical Billing. Sometimes the physician cannot provide his entire attention to this activity. He entrusts this activity to Billing Companies. This is a process of the physician providing rights to Billing Companies to bill Medical Insurance claims in order to save his time energy, and money.

After the provider renders services to the patient, the billing company will submit bills to the insurance company/ payer, using the insurance information that was last provided, as well as information about the reason for the examination, and the exact type of procedure performed.

Initial Health Assessment process in HMO

Initial Health Assessment

As a Medicare Advantage Organization, BCBSF must make a reasonable effort to complete an initial health assessment for each BlueMedicare HMO, BlueMedicare PPO and BlueMedicare PFFS member within 90 days of enrollment to identify members with potential serious and/or complex medical conditions. BCBSF will notify the member’s in-network primary physician if:

* The member refuses the assessment.

* The member is placed in the high-risk category and the member consents to the release of the results.

Billing qualifier ID and its meaning

0B – ANSI – State License#

1A – ANSI – Blue Cross Provider ID#

1B – ANSI – Blue Shield Provider#

1C – ANSI – Medicare Provider#

ID – ANSI – Medicaid Provider#

IG – ANSI – Provider UPIN#

1H – ANSI - CHAMPUS ID#

1J – ANSI - Facility ID#

B3 – ANSI - Preferred Provider Org

BQ – ANSI - Health Maintenance Org Code#

EI – ANSI - Employers ID#

FH – ANSI - Clinic#

G2 – ANSI - Provider Commercial#

G5 – ANSI - Provider Site#

LU – ANSI - Location#

SY – ANSI - Social Security#

U3 – ANSI - The Social Security# may not be used for

X5 – ANSI – Medicare. Unique Supplier ID# (USIN)

N4 – ANSI – Provider plan Network ID#

ZZ – ANSI – Taxonomy code

Selecting the Right Medical Billing Service - 5 Things to Consider

Medical billing is crucial part of any health care facility even though it is not the main line of activity in such workplaces. There are many time consuming issues related to medical billing. Medical professionals are often overworked, and may not have time to attend to such issues. But ignoring this function may lead to severe repercussions such as drying up of funds, or even legal complications related to Medicare frauds. Therefore, this function deserves due respect.

One way to reduce medical billing procedures encroaching upon the health care functions is to off load the function to specialized medical billing services. Such offloading is advantageous even for smaller medical practices, as it leaves more time on hand for the professional work. There are many medical billing service providers. It becomes difficult to select the right one from these. In order to get the right medical billing company, following five points need to be considered. 

1.    Where is the medical billing service located?

Location of such services is crucial because patients often have queries regarding their medical bills. Services of overseas medical billing companies are cheaper, but they may prove to be expensive for patients. In addition, there can be other issues such as accent or lack of familiarity with procedures in the country where health care facility is located.

2.    Is the medical billing company adequately experienced?

Experience is very important in this field. This is because terminology related to medical billing is quite different from other types of billing. In addition, billing is linked to medical reimbursements. Therefore, any such billing information should be accurate. It should also comply with all relevant legal stipulations. 

3.    How efficient is the medical billing service in getting reimbursement?

Medical billing is a set of smaller functions like entering data, submitting claims for getting reimbursement, patient billing, payment posting, and follow up for reimbursement, and handling denial issues. The company that offers comprehensive service should be preferred over others. In addition, the company that systematically and regularly obtains the reimbursements in shorter time should be preferred. 

4.    What sort of reports can the company generate, and how frequently?

Medical billing is not exclusively about generating bills, and obtaining reimbursements. It is also about generating different reports from the available data. Such reports should give the medical professional an idea about the financial health of the practice or health care facility as the case may be.

5.    Does the company guarantee data security?

There are legal stipulations relating to patient’s rights to privacy. Security of medical billing data is therefore important because information on it can lead to Medicare and other frauds, which could implicate the health care facility and lead to protracted legal battles. 

Medical billing contract - things to consider - reponsiblity and duty

Medical Billing Contracts

If you are going to try and create your own medical billing company, you should have a medical billing contract.  You can either have a basic contract, or have an attorney draft up a contract.  

In the contract there are some things to consider

Name of the billing company and the name of client.

Effective date of contract and expiration date if any.

Where will the insurance payments go to?  I recommend having the payments go to the physician's office to avoid any legal matters. There should be a contract stating the provider will send copies of EOB's of all payments.

Providing monthly reports or meeting once a month or quarterly.

How will payments be made?  You can either charge by percentage. Some of the average ranges are 8 to 15% or an average of $4 to $10 per claim.  Things to consider are the patient volume, average income and if the client is established or not.

Who will do the coding?  You will want to interview the company that you will be outsourcing with to make sure they are not doing anything illegal first.  You do not want to do billing for a company that is in violation.

Once you have interviewed with them, you can either agree to have coding stay with them or choose to outsource coding as well for an additional fee.

Things that the client is responsible for: 

provide true and accurate data(the client will be responsible for any submission of false date that can be prosecuted by law)

verify insurance

client will be responsible for his/her own credentialing

client will not offer kickbacks or professional courtesy to client(this means the client can not wave copay or give free services to preferred patients, THIS IS AGAINST THE LAW)

      

Note that claims and patient information belongs to the property of the client and the billing company is only using it while contracted with the client.

Billing company is responsible for 

following up on unpaid claims

patient billing

paper and electronic submission of claims

If you are going to try and create your own medical billing company, you should have a medical billing contract. You can either have a basic contract, or have an attorney draft up a contract.

In the contract there are some things to consider

Name of the billing company and the name of client.

Effective date of contract and expiration date if any.

Where will the insurance payments go to? I recommend having the payments go to the physician's office to avoid any legal matters. There should be a contract stating the provider will send copies of EOB's of all payments.

Providing monthly reports or meeting once a month or quarterly.

How will payments be made? You can either charge by percentage. Some of the average ranges are 8 to 15% or an average of $4 to $10 per claim. Things to consider are the patient volume, average income and if the client is established or not.

Who will do the coding? You will want to interview the company that you will be outsourcing with to make sure they are not doing anything illegal first. You do not want to do billing for a company that is in violation.

Once you have interviewed with them, you can either agree to have coding stay with them or choose to outsource coding as well for an additional fee.

Things that the client is responsible for: provide true and accurate data(the client will be responsible 

for any submission of false date that can be prosecuted by law)

verify insurance

client will be responsible for his/her own credentialing

client will not offer kickbacks or professional courtesy to client(this means the client can not wave 

copay or give free services to preferred patients, THIS IS AGAINST THE LAW)

Note that claims and patient information belongs to the property of the client and the billing company is only using it while contracted with the client.

Billing company is responsible for following up on unpaid claims

patient billing

paper and electronic submission of claims 

Main benefits in outsourcing

Benefits of outsourcing

If you are finding that you’re chasing medical billing claims and having a lot of rejections, it may not be your staff, it might be that they are unable to keep up with the fast pace of the ever-changing medical billing industry. It might be time to consider outsourcing your medical billing claims. And you can get a lot more than just have your medical billing claims handled.  We can provide a complete medical billing service for your practice. It will include filing both your electronic and paper claims along with any necessary consulting. We also offer comprehensive medical coding services. This includes analysis of your claims, coding audits and consulting

.

Credentialing Information Review and contracting decision

Credentialing Information Review

Providers have the right to review and correct information submitted in support of their credentialing application and/or obtained from third party sources, excluding peer review and NPDB findings (if NPDB or HIPDB is applicable to the provider type). If corrections are needed, providers must submit corrected information by the date requested by BCBSF and, in all cases, no later than the completion of the credentialing process. Providers have the right to contact their local BCBSF office for a status of their credentialing application.

Ten things you should know about Medical billing

1 .Medical Billing is the process of submitting and following up on claims to insurance companies in order to receive payments for medical services rendered by a health care provider.

2--What is the Medical Billing Process?

The Medical Billing process is an interaction between the healthcare provider and the Insurance Company. After examining the patient, the doctor maintains a medical record. This Record includes the patients' symptoms, clinical findings, and diagnosis and treatment details. Following these details a medical coder or a billing specialist provides a medical code for this record. This billing code is then submitted to the Insurance Company. The Insurance Company then proceeds with the claim.

3-- What about the Payment?

Based on the amount negotiated by the doctor and the insurance company, the original charge is reduced.

4--What about the Billing Quality?

Billing Quality is measured in terms of timeliness and completeness of payment. The shape of the distribution curve of Accounts Receivable illustrates billing quality. For several decades, medical billing was done almost entirely on paper. However, with the advent of computers it has become possible to efficiently manage large amounts of claims. Many software companies have arisen to provide medical billing software to this particularly lucrative segment of the market.

5—What are the Medical Billing mistakes you should avoid?

Physicians believing that their billing professional care a lot and will not be doing any mistakes is at the head of the list.Take a copy of patients Insurance card. Also a second ID. Secure sign advanced Beneficiary notice when indicated.

what is provider recredentialing

Recredentialing of Health Options, Medicare Advantage and NetworkBlue participating providers is performed by BCBSF triennially, in its sole discretion and will require the submission of updated credentialing information. Any such information is reviewed and attempts are made to verify certain information using available third party sources. BCBSF queries the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank as part of the recredentialing process.

The recredentialing information is reviewed by the Network Management Committee for a final decision regarding continued participation. All such decisions are solely within the discretion of the Network Management Committee.

physician enrollment - what are the documents required? Physicians and Ancillary Professional Providers

Physicians and individual ancillary professional providers (excludes ancillary facilities) can also electronically submit or update provider application data directly through the CAQH website at www.CAQH.org/cred. For more information on CAQH, call the CAQH Helpdesk at (888) 599-1771.

Based on the type of services performed by the provider, the appropriate documentation will need to be provided before the Agreement may become effective. While the specific information required is subject to the discretion of BCBSF and may vary depending upon provider type, the following is a list of the type of information that may be required:

Completed credentialing application

Signed attestation statement

Copy of Florida license(s)

Copy of Florida registration Education and training, if applicable

Work history for the past five years

Copy of specialty board certificate (if applicable)

Hospital admitting privileges

Current certification of insurance (face sheet with expiration date and coverage amounts)

Explanations for malpractice history and disciplinary actions

Copy of Health and Rehabilitative Services (HRS) and/or Medicare site survey

Copy of Medicare certification(s)

Reason to why outsource medical billing claim to third party

Outsourcing your medical billing claims to a third party partner may be one of the smartest business moves you make in 2010.

You may have had every intention of doing your own medical billing for your practice from the day you opened until the day you retired, however with the never ending changes and nuances in medical billing claims varying from cancelled codes to nonpayment of certain procedures because they simply weren’t reported correctly – there comes a time when you need to look at your revenue flow from your reimbursements and decide it might be time to outsource your medical billing claims.

Urgent care and emergence room - payment different Emergency Care - BCBS

Will the amount I pay be different if I go to an urgent care center vs. an emergency room?

Benefits vary by plan, but typically your co-pay will be lower if you visit an urgent or ambulatory care center. Whenever possible, you should avoid hospital emergency rooms unless the emergency is life threatening. View Current Benefits located under the Benefits menu.

When should I go to an urgent care center (walk-in clinic) vs. an emergency room?

     For non-emergency assistance, urgent care centers (also called ambulatory care centers) provide prompt, quality service. They are staffed with qualified doctors and nurses who can handle medical problems like cuts and colds, flu symptoms, minor fractures, sprains and burns, ear infections, allergic reactions, animal bites, sprains and even immunizations.

     In a medical emergency—including shortness of breath, severe abdominal or chest pains, uncontrolled bleeding, loss of consciousness, changes in vision, severe vomiting or other life-threatening condition—call 911 or visit the nearest hospital emergency room.

tissue adhesives CPT 12001 -12018 or G0168

When you code for the use of tissue adhesives, including Dermabond; Medicare has its own guidelines for reporting this procedure that you need to follow to be reimbursed. You should report G0168 for Medicare patients only. If you are reporting the procedure for a non-Medicare patient, you should use the CPT code that is the equivalent and that is 12001-12018 series (Simple repair of superficial wounds …).

Another tip for reporting this claim to Medicare is you may only use G0168 for Dermabond-only laceration repairs in both the inpatient and outpatient settings. If sutures or staples were also used you will have to report this as a layered laceration code on your medical billing form.

Something you may not be aware of is that Medicare assigns a payment status indicator of “N” to G0168, meaning it represents an incidental service. You can report the code but you won’t receive any reimbursement for it from Medicare payers.

Private payers will have different guidelines, a quick check with the payers to see if they follow Medicare guidelines for this type of procedure will let you know whether or not to expect a reimbursement for the service.

non covered CPT for assistant surgeon 10021 - 17340

10000 series procedure codes that are "Nevers" for Assistant Surgeon

The below table identified procedure codes that are not eligible for reimbursement when reported by an Assistant Surgeon.

10021 11311 11643 12007 14020 15261 15789 16000 19001

10022 11312 11644 12011 14021 15300 15792 16020 19020

10040 11313 11646 12013 14040 15301 15793 16025 19030

10060 11400 11719 12014 14041 15320 15819 16030 19100

10061 11401 11720 12015 14060 15321 15820 16035 19101

10080 11402 11721 12016 14061 15330 15821 16036 19102

10081 11403 11730 12017 14350 15331 15822 17000 19103

10120 11404 11732 12020 15002 15335 15823 17003 19105

10121 11406 11740 12021 15003 15336 15824 17004 19110

10140 11420 11750 12031 15004 15340 15825 17106 19112

10160 11421 11752 12032 15005 15341 15826 17107 19120

10180 11422 11755 12034 15040 15360 15828 17108 19125

11000 11423 11760 12035 15050 15361 15829 17110 19126

11001 11424 11762 12036 15100 15365 15833 17111 19290

11004 11426 11765 12037 15101 15366 15834 17250 19291

11005 11307 11640 12004 13160 15240 15786 15950 17360

11006 11308 11641 12005 14000 15241 15787 15951 17380

11008 11310 11642 12006 14001 15260 15788 15953 19000

11010 11440 11770 12041 15110 15400 15835 17260 19295

11011 11441 11771 12042 15111 15401 15836 17261 19296

11012 11442 11772 12044 15115 15420 15837 17262 19297

11040 11443 11900 12045 15116 15421 15838 17263 19298

11041 11444 11901 12046 15120 15430 15839 17264 19300

11042 11446 11920 12051 15121 15431 15850 17266 19301

11043 11450 11921 12052 15130 15570 15851 17270 19324

11044 11451 11922 12053 15131 15572 15852 17271 19325

11045 11462 11950 12054 15135 15574 15860 17272 19328

11046 11463 11951 12055 15136 15576 15876 17273 19330

11047 11470 11952 12056 15150 15600 15877 17274 19340

11055 11471 11954 13100 15151 15610 15878 17276 19342

11056 11600 11960 13101 15152 15620 15879 17280 19350

11057 11601 11970 13102 15155 15630 15920 17281 19355

11100 11602 11971 13120 15156 15650 15931 17282 19370

11101 11603 11975 13121 15157 15736 15933 17283 19371

11200 11604 11976 13122 15170 15740 15934 17284 19380

11201 11606 11977 13131 15171 15760 15936 17286 19396

11300 11620 11980 13132 15175 15775 15937 17311

11301 11621 11981 13133 15176 15776 15940 17312

11302 11622 11982 13150 15200 15780 15941 17313

11303 11623 11983 13151 15201 15781 15944 17314

11305 11624 12001 13152 15220 15782 15945 17315

11306 11626 12002 13153 15221 15783 15946 17340

When billing Medicare for DERMABOND® Portfolio, it is appropriate to bill either the laceration repair CPT code or the HCPCS for Wound Closure utilizing tissue adhesive. Private payers and Medicaid programs may allow physicians to bill both a CPT and the HCPCS code. Please check with the payer regarding specific coding guidelines.

CPT/HCPCS Codes Level of Complexity 2012 Medicare National Reimbursement Ranges (Physician Office)2012 Medicare National

Reimbursement Ranges (Hospitals) CPT 12001-

12021 Simple $ 93.90 - $ 274.00 $ 49.69 - $ 186.67

CPT 12031- 12057  Intermediate $ 235.20 - $ 618.12 $ 153.17 - $ 402.32

CPT 13100- 13160 Complex   $ 108.92 - $ 810.78 $ 75.56 – 810.78

HCPCS G0168 Wound Closure utilizing tissue adhesive(s) only $ 86.03 $ 26.55

SIMPLE REPAIR CPT Codes – Simple Repair Primarily involves a superficial, one layer closure of epidermis, dermis, or subcutaneous tissues 2012 Medicare National Average – Physician Office (Non Facility) 2012 Medicare National Average – Physician (Facility )

12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less $ 93.90 $ 49.69

12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm $ 111.64 $ 64.67

12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm $ 131.73 $ 79.65

12005 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm $ 170.19 $ 106.20

12006 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm $ 205.25 $ 129.68

CPT Codes for Laceration Repair Laceration CPT Medicare 110% Medicare 120% Medicare

Simple/Superficial-Scalp, Neck, Axillae, External Genitalia, Trunk, Extremities

 2.5 cm or less 12001 $137.19 $150.91 $164.63  2.6 cm to 7.5 cm 12002 $145.53 $160.08 $174.64  7.6 cm to 12.5 cm 12004 $170.54 $187.59 $204.65  12.6 cm to 20.0 cm 12005 $212.60 $233.86 $255.12  20.1 cm to 30.0 cm 12006 $263.77 $290.15 $316.52
 over 30.0 cm 12007 $298.25 $328.08 $357.90 Simple/Superficial-Face, Ears, Eyelids, Nose, Lips, Mucous Membranes

 2.5 cm or less 12011 $145.15 $159.67 $174.18

 2.6 cm to 5.0 cm 12013 $159.55 $175.51 $191.46

 5.1 cm to 7.5 cm 12014 $187.97 $206.77 $225.56

 7.6 cm to 12.5 cm 12015 $235.72 $259.29 $282.86

 12.6 cm to 20.0 cm 12016 $278.93 $306.82 $334.72

 20.1 cm to 30.0 cm 12017

 over 30.0 cm 12018

Simple repair codes 12001 - 12021 are used when the wound only involves the epidermis and/or dermis. The wound does not extend into the deeper subcutaneous tissues. The repair is a simple one layer closure and may be performed with the use of tissue adhesives, staples or suture material.

Effective Jan. 1, 2005, code G0168 wound closure using adhesives only, was changed to an APC status indicator of "N" and will no longer be paid separately. 

A simple repair reported with code only G0168 will not be reimbursed. The code for the simple repair is assigned from code range 12001-12018 and an additional code for the wound adhesive G0168 may also be assigned. 

Correspondence Language Policy/Example Number 3.10000 - CPT Manual or CMS manual coding instruction

For example, the CPT Manual instruction under “Excision - Benign Lesions”, states that the excision includes simple closure. Therefore the procedure described by the column one CPT code 11400 (“Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 0.5 cm or less”) includes the procedure described by the column two CPT code 12001 (“Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5cm or less”). CPT code 12001 is bundled into CPT code 11400.

Correspondence Language Policy/Example Number 4.10000 - Mutually exclusive procedures

For example, a physician performing a destruction of a malignant lesion of the arm by laser surgery, electrosurgery, cryosurgery, chemosurgery, or surgical curettement (CPT code 17260) would not also report an excision of the same malignant lesion of the arm (CPT code 11600). 

Only one method of treatment of the malignant skin lesion would be performed at a single patient encounter. Therefore, CPT codes 17260 and 11600 are mutually exclusive of each othe 

Laceration Repairs

* Repairs – Simple, Intermediate, and Complex (12001-13160)

* CPT® code is selected based on the length of the closure. If two closures of the same type and within the same ‘anatomic category’, combine the lengths and use one code. 

NCCI Manual – ATT

* When lesion excision is of such an extent that closure cannot be accomplished by simple, intermediate, or complex closure, other methodology must be employed.

* Frequently adjacent tissue transfer or tissue rearrangement is employed (Z-plasty, W-plasty, flaps, etc.). This family of codes, (CPT® codes 14000-14350), involves excision with adjacent tissue transfer and correlates to excision codes.

Excision CPT® codes (11400-11646) and repair CPT® codes (12001 – 13160) are not to be separately reported when CPT® codes 14000- 14350 are reported. 

Medical billing service - what does it include

Understand what a Billing Service can do? Before deciding whether outsourcing your billing would help your practice, be sure you know what a billing service can offer you. Different firms provide different services and equipment, but they typically include the following:

-Data entry of patients' demographic and billing information, charges, receipts and adjustments;

-Production and submission of claims, both electronic and paper-based;

-Production and mailing of patient statements;

-Collection and tracking of payments from third parties and patients;

-Purging of inactive accounts;

-Production of management reports;

-Installation of computer terminals and printers so the practice can perform queries, update records, schedule appointments, and generate demand reports, demand statements and super bills.

-Identify your needs and wants

Medical billing service - what does it include

 Medical Billing Service  is a great solution for some practices and a disaster for others. Why it becomes a disaster and why most of the physician failed to opt a better medical billing service. What makes the disparity? Your certain requirements, needs and the selection criteria you use, are critical in deciding the right medical billing company. Further than, you need to appraise the presentation of any medical billing service you consider and recognize exactly what services you're purchasing. Here is course of actions you may need to consider when deciding a medical billing service. Besides, these guidelines, probabilities of disaster can be reduced when you decide to turn over your billing function to a third party (medical billing service provider).

Locum tenens billing with modifier Q6

Locum tenens is a confusing situation in the case where a physician takes a vacation or otherwise isn’t available and hires a physician to see patients on site, Medicare can deny the claim unless it is properly documented. The reason is that Medicare is very strict about seeing specific modifiers on medical billing claims that involve a substitute or locum tenens physician.

Further, your medical billing claim must have the time limits observed for locum tenens doctors. Otherwise, Medicare won’t pay for their services rendered to patients. Also, you can’t hire a locum tenens as extra staff. 

This includes situations where the regular attending physician goes on vacation, has an illness with a lengthy recovery time, maternity or family healthy leave, or educational reasons such as attending continuing medical education classes. When you use a locum tenens physician it must always be in the capacity as a temporary replacement that substitutes for the services of a specific physician.

Remember to use Modifier Q6 on all your locum tenens claims. There are some extra steps that must be taken in order for your locum tenens claims to be reimbursed by Medicare. The Q modifier should be listed as a procedure code so Medicare knows you’re claiming services rendered by a locum tenens physician. If you don’t use the modifier, you claim will likely be denied. 

Also the maximum time limit for billing for locum tenens physicians is currently sixty days for Medicare and private payers will have different criteria for length of service. Call before you file is a good rule of thumb, you may be missing reimbursements if you don’t. Some good questions to ask would be if the payer requires the locum tenens be credentialed even for a short period of service time; also, which provider’s ID would they prefer to be reported?

Using the correct modifier and a call before you file can save you a lot of hassles and delays in receiving your reimbursements for the locum tenens type of medical billing claims.

Hospice modifiers list GV,GW, GJ , Q5, Q6

Hospice Modifiers Fact Sheet

Definitions:

**  GV - Attending physician not employed or paid under agreement by the patient's hospice provider.

**  GW - Service not related to the hospice patient's terminal condition

**  Q5  - Service furnished by a substitute physician under a reciprocal billing arrangement

**  Q6 - Service furnished by a locum tenens physician

Modifier GJ "Opt out" physician or practitioner emergency or urgent services

Facts

** Modifiers are billed when a patient is enrolled in a Hospice.

** Modifier GW is used when a providers of services (physican, ambulance supplier, etc.) is performing services not related to the hospice diagnosis.

** Modifier GV is used when the physician performing services is not employed by the hospice and is designated as the attending physician.

** Certain Medicare beneficiaries can choose hospice benefits instead of Medicare for treatment and management of their terminal condition.

** The beneficiary waives all rights to Medicare Part B payments for services except for professional services of an “attending physician.” (In this case “attending physician” is defined as a doctor of medicine or osteopathy who is identified as having the most significant role in the determination and delivery of their medical care.)

** The professional services of an attending physician are not considered hospice services.

** The services of the attending physician are billed to Medicare Part B with modifier GV modifier Attending physician not employed or paid under agreement by the patient's hospice provider as long as the provider does not have a payment arrangement with the hospice. In the latter case the services are billed by the hospice to Medicare Part A.

** If a substitute or locum tenens physician provides services, the designated attending physician bills the services using modifier GV and either the Q5 or Q6 modifier.

Here are some examples to give a better understanding of the use of these modifiers:

Example 1: A beneficiary is enrolled in Hospice and goes to a physician's office for closed treatment of a metatarsal fracture, CPT code 28470.

Resolution: If the procedure is unrelated to the terminal prognosis (Non-Hospice related), the physician's bill should contain GW modifier (Service not related to the hospice patients terminal condition). If this modifier is not appended, the procedure is related to the terminal prognosis and should not be reimbursed under the part B benefit. Thus, the claim is in error, since the services are considered included with payments under the hospice benefit.

Example 2: The patient is listed as being on hospice starting August 1, 2010 through August 31, 2010. Then a provider billed CPT code 45378, Diagnostic Colonoscopy with no modifiers on August 3, 2010 to Part B.

Resolution: The billing of code 45378 would be incorrect since the beneficiary was enrolled in hospice and there can be no separate reimbursement unless the service was unrelated to the terminal prognosis or the attending physician was otherwise entitled to separate reimbursement, which would be reflected by GV modifier (Attending physician not employed or paid under arrangement by the patients hospice provider) or GW modifier (Service not related to the hospice patients terminal condition). 

MACs should also deny services that are submitted with the modifier but for which, during medical review, the service is determined to be related to the terminal prognosis.

Guidelines/Instructions for Modifier GV

The attending physician is not employed or paid under agreement by the patient's Hospice provider.

Instructions

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

Service was rendered to a patient enrolled in a Hospice.

Service was provided by a physician or non-physician practitioner identified as the patient's  'attending physician' at the time of that patient's enrollment in the Hospice program

Submit this modifier regardless of whether the services were related to the patient's terminal condition

Service was provided by a physician employed by the Hospice, you may not submit this modifier

Service was provided by a physician not employed by the Hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier

Example:  An independent attending physician or independent laboratory interprets the surgical pathology (88305) from a patient with a terminal illness related service. The professional component is billed to the Medicare contractor. If there is no professional component (e.g., clinical lab tests), then the Part A Hospice should only be billed.

Date of Service    Treatment   CPT/Modifier

01/14/12 Surgical pathology (professional component) Bill to Part B: 88305 26GV

01/14/12 Surgical pathology (technical component) Bill to Hospice: 88305 TC

Same rules apply for diagnostic tests

Date of Service  Treatment CPT/Modifier

09/25/12 Chest x-ray (professional component) Bill to Part B: 71010 26GV

09/25/12 Chest x-ray (technical component) Bill to Hospice: 71010 TC

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

The service was rendered to a patient enrolled in a hospice.

The service was provided by a physician or non-physician practitioner  identified as the patient’s “attending physician” at the time of that patient’s enrollment in the hospice program.

Submit this modifier regardless of whether the services were related to the patient’s terminal condition.

If the service was provided by a physician employed by the hospice, you may not submit this modifier.

If the service was not provided by a physician employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier.

For beneficiaries enrolled in hospice, MACs should deny any Part B services furnished on or after January 1, 2002, that are submitted without either GV modifier, meaning the attending physician is not employed or paid under arrangement by the beneficiary's hospice provider and professional services provided are related to the terminal prognosis, or GW modifier, meaning the service is not related to the hospice beneficiary's terminal prognosis. 

MACs should deny services that are submitted with the GW modifier when the service is determined to be related to the terminal prognosis. Also, MACs should deny services that are submitted with the GV modifier if it is determined that the Physician services were furnished by Hospice-employed physicians and Nurse Practitioners (NP) or by other physicians under arrangement with the Hospice.

HCPCS Modifier GV Description:

Attending physician not employed or paid under arrangement by the patient’s hospice provider.

Guidelines/Instructions:

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

** The service was rendered to a patient enrolled in a hospice.

** The service was provided by a physician or non-physician practitioner identified as the patient’s “attending physician” at the time of that patient’s

enrollment in the hospice program.

** Submit this modifier regardless of whether the services were related to the patient’s terminal condition.

** If the service was provided by a physician employed by the hospice, you may not submit this modifier.

** If the service was not provided by a physician employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier.

Guidelines/Instruction for Modifier GW

Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient’s terminal condition. All providers must submit this modifier when this condition applies.

For services provided to beneficiaries enrolled in hospice, all providers must submit one of the above applicable modifiers on the detail service line for the service.

Services submitted for a “hospice” beneficiary without one of the hospice modifiers will be denied