Training Material

Medical Billing
Day 1
 What is RCM
• Revenue cycle management (RCM) for healthcare providers refers to the process of
managing the financial aspects of a patient’s visit to a healthcare facility, from appointment
scheduling to claims processing and payment collection. It covers everything from a patient’s
initial appointment to the final payment approval by the payor.

• The RCM process involves multiple steps, including submitting medical billing claims to
insurance companies, assigning appropriate medical codes to procedures, converting medical
services into billable charges, and collecting payments from patients for any outstanding
balances. Further details about the RCM process are provided later in the article.
 RCM ( Revenue Cycle Management )

.
 Scheduling Appointments
• The first step in the revenue cycle management process is scheduling an appointment with
the patient. This involves collecting their personal and medical information, such as name,
date of birth, insurance details, and reason for the visit.

• The demand for virtual assistants continues to increase, and appointment scheduling is one
area where virtual receptionists excel.

• Questions
• Name, DOB
• Appointment date
• Appointment time
• Also Need to confirm day before Appointment date.
 Patient Registration
• After scheduling an appointment, the patient must complete registration
forms that include their demographic and medical information. This data is
used to verify eligibility and benefits, as well as to provide accurate billing.
 Eligibility and Benefits Verification
• To determine their payment responsibility, healthcare providers must verify patients’
insurance coverage and benefits. This involves checking the patient’s insurance plan for co-
pays, deductibles, and other payment details.

• Quetions
• Plan Active and temrmination Date
• Pt have Secondary Insurance?, if yes ask for member ID and which insurance is PRIMARY
• In network or Out of network
• Authorization is required for ( 99213, J9801, S9088 )
• Copay, Co insurance, Deductible, Out of pocket
 Utilization Review
• Utilization review ensures that healthcare services provided to patients are medically
necessary and meet insurance coverage criteria. This review is conducted to prevent
unnecessary treatments that may result in claim denials or non-payment.

Referral
• Some insurance plans require a referral or authorization from a primary care
physician or insurance company before receiving specialty care or services. The
healthcare provider must ensure that the patient has obtained the necessary
referral or authorization before rendering services.
 Describing Charges
• Healthcare providers must provide a detailed description of the charges incurred during a
patient’s visit. This includes services rendered, medications prescribed, and any medical
devices used.

Coding and Billing

• The coding and billing step involves assigning appropriate codes to medical procedures and
services, ensuring that the claim accurately reflects the care provided. This process helps to
avoid claim denials or incorrect payments.
• With the continuous changes in billing codes and administrative practice personnel under
constant pressure, ideal conditions are created where revenue can leak from the practice.
This is where revenue cycle management specialists like Neolytix remain focused due to
their extensive resources and expertise.
 Charge Posting
• After billing the insurance company, healthcare providers post the charges to the patient’s
account. This step ensures that the patient’s account balance is up-to-date

Submitting Claims
• Once the charges have been posted, the healthcare provider submits the claim to the
insurance company for payment.
 Clearinghouse Rejections
• Sometimes, insurance companies deny claims due to incorrect coding or incomplete
information. Healthcare providers use clearinghouses to track and manage these claim
denials.

Payment Posting
• After the insurance company approves the claim, the payment is posted to the patient’s
account. This step ensures that the patient’s account balance reflects the payment received.
 Denial Management
• Denial management involves resolving any claim denials or issues that may arise.
Healthcare providers must identify the cause of the denial and take the necessary steps to
resubmit the claim for payment.

Accounts Receivable
• The accounts receivable step involves managing the patient’s outstanding balances. This
step ensures that the patient’s account remains up-to-date and that the healthcare provider
receives payment for the services rendered.
 Appeal Procedure
• If a claim is denied, healthcare providers can appeal the decision. The appeal procedure
involves providing additional documentation or information to support the claim and to
ensure payment.

Patient Billing Collections

• The final step of the revenue cycle management process is patient billing collections. This
step involves sending out statements or invoices to patients for outstanding balances. The
healthcare provider may also work with a collection agency to collect payment.
Day 2
 Private Insurance
• Private insurance is provided by Pricate companies like BCBS, Aetna, Novitas, UHC, Cigna
etc.

• Person can buy Private insurance on his own by paying premium

Commercial Insurance
• Commercial insurance is provided by Company for workers.

• Commercial insurance is also called Business insurance.

 Government Insurance
• Medicare:- The federal health insurance program for:
• People who are 65 or older
• Certain younger people with disabilities
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
transplant, sometimes called ESRD)

• Medicaid:- Medicaid is a joint federal and state program that helps cover medical
costs for some people with limited income and resources.

• Medicaid is for poor peoples.

• Tricare:- Tricare (styled TRICARE) is a health care program of the United States
Department of Defense Military Health System. Tricare provides civilian health benefits for
U.S Armed Forces military personnel, military retirees, and their dependents, including some
members of the Reserve Component.
 Type of Medicare
• There are four parts of Medicare: Part A, Part B, Part C, and Part D.

• Part A provides inpatient/hospital coverage.

• Part B provides outpatient/medical coverage.
• Part C offers an alternate way to receive your Medicare benefits (see below for more
information).
• Plans that covers medicare under Part C
• HMO: Health Maintenance Organization
• PPO: Preferred Provider Organization
• POS: Point of Service
• EPO: Exclusive Provider Organization

• Part D provides prescription drug coverage.

 Medicare Part A
• Inpatient care in a hospital
• Skilled nursing facility care
• Nursing home care (inpatient care in a skilled nursing
facility that’s not custodial or long-term care)
• Hospice care
• Home health care
 In Patient
• Inpatient care is care provided in a hospital or other type of inpatient facility, where you are
admitted, and spend at least one night—sometimes more—depending on your condition.

Skilled Nursing Facility

• A skilled nursing facility is an in-patient treatment and rehabilitation center featuring licensed
nurses and other medical professionals.
• These services can be very expensive but most skilled nursing facilities are covered, at least
in part, by private health insurance or else Medicare or Medicaid.
• Patients in a skilled nursing facility can be expected to remain there temporarily, in contrast
to a more permanent nursing home setting.
 Nursing Home
• A public or private residential facility providing a high level of long-term personal or nursing
care for persons (such as the aged or the chronically ill) who are unable to care for
themselves properly

Hospice Care
• Hospice care focuses on the care, comfort, and quality of life of a person with a serious
illness who is approaching the end of life. At some point, it may not be possible to cure a
serious illness, or a patient may choose not to undergo certain treatments. Hospice is
designed for this situation.
 Home Health Care
• Home health is a nursing specialty in which nurses provide multidimensional home care to
patients of all ages. Home health care is a cost efficient way to deliver quality care in the
convenience of the client's home. Home health nurses create care plans to achieve goals
based on the client's diagnosis.
 Medicare Part B
• Medicare Part B helps cover medical services like doctors' services, outpatient care, and
other medical services that Part A doesn't cover. Part B is optional. Part B helps pay for
covered medical services and items when they are medically necessary.
• Services from doctors and other health care providers
• Outpatient care
• Home health care
• Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)
• Many preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits)
 Out Patient
• Outpatient care refers to any healthcare consultation, procedure, treatment, or other service
that is administered without an overnight stay at a hospital or medical facility. Unlike inpatient
care, patients receiving outpatient care are free to leave the medical facility once the service
or procedure is complete.

• Outpatient care is administered in various outpatient facilities such as primary care clinics,
community health centers, urgent care clinics, and ambulatory surgery centers.
What Part C health plan covers
 Medicare Part D
• Medicare Part D is a voluntary outpatient prescription drug benefit for people with Medicare
provided through private plans that contract with the federal government.

• Medicare Part D covers Drug ( medicine )

 Codes That we bill
• CPT Code:- Current Procedural Terminology
• Doctor perfom any service or surgery than we have to bill CPT code to indentify the service
or surgery.

• NDC Code:- National Drug Code

• If doctor give any Medicine than we have to bill NDC code to indetify the Medicine
 Day 3

•
 Diagonsis Code
• DX Code:- A diagnosis code is a combination of letters and numbers that represents
a certain medical condition, procedure, symptom, or disease

• In 2023 we use ICD-10 approved Diagnosis code, every Year ICD change.

• Modifer:- If more than one service is perfomed on single

than we need to bill modifier with every CPT code to
differenticate the services.
 Place Of Service
• A facility or location where drugs and other medically related items and
services are sold, dispensed, or otherwise provided directly to patients.

• Place of Service Codes are two-digit codes placed on health care

professional claims to indicate the setting in which a service was provided
 Place of Service Codes
• 02 :- Telehealth The location where health services and health related services are provided
or received, through a telecommunication system.

• 11 :- Office Location, other than a hospital, skilled nursing facility (SNF), military treatment
facility, community health center, State or local public health clinic, or intermediate care
facility (ICF), where the health professional routinely provides health examinations,
diagnosis, and treatment of illness or injury on an ambulatory basis.

• 15 :- Mobile Unit A facility/unit that moves from place-to-place equipped to provide

preventive, screening, diagnostic, and/or treatment services.

• 20 :- urgent Care Facility Location, distinct from a hospital emergency room, an office, or a
clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory
patients seeking immediate medical attention.
• 21 :- Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic,
therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the
supervision of physicians to patients admitted for a variety of medical conditions.

• 22 :- Outpatient Hospital A portion of a hospital’s main campus which provides diagnostic,

therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured
persons who do not require hospitalization or institutionalization.

• 23 :- Emergency Room – Hospital A portion of a hospital where emergency diagnosis and

treatment of illness or injury is provided.

• 24 :- Ambulatory Surgical Center A freestanding facility, other than a physician’s office,

where surgical and diagnostic services are provided on an ambulatory basis.

• 25 :- Birthing Center A facility, other than a hospital’s maternity facilities or a physician’s

office, which provides a setting for labor, delivery, and immediate post-partum care as well as
immediate care of new born infants.
• 26 :- Military Treatment Facility A medical facility operated by one or more of the Uniformed
Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health
Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities
(USTF).

• 31 :- Skilled Nursing Facility A facility which primarily provides inpatient skilled nursing care
and related services to patients who require medical, nursing, or rehabilitative services but
does not provide the level of care or treatment available in a hospital.

• 34 :- Hospice A facility, other than a patient’s home, in which palliative and supportive care
for terminally ill patients and their families are provided.

• 41:- Ambulance – Land A land vehicle specifically designed, equipped and staffed for
lifesaving and transporting the sick or injured.
 Tyes of Claim form
• CMS-1500 for professional billing

• UB-04:- Institutions use the UB-04 form to bill insurance for inpatient or outpatient
medical and mental health claims.

• Dental Claim:-
CMS- 1500
Dental
UB