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.

• The provider will provide written documentation of the diagnosis and ICD9 code either on the PCC form or in the Electronic Health Record.

• Depending on the facility, the coder or biller will validate the provider’s coding.

• A coder or biller should never modify documentation by a provider. If a provider fills out a charge ticket and signs it or completes an EHR with an electronic digital signature, then that document is a legal record and should not be altered.

• If the diagnosis code listed by the provider differs from the coder/biller, the coder or biller must review the discrepancy with the provider. If the provider agrees with the coder/biller, the provider must change the code and initial the claim (either the PCC or as an amended claim in the Electronic Health Record).

• All Medicare, Medicaid, and private insurer claims require a linkage or a relationship between the CPT and ICD-9-CM codes.

• Current Physician Terminology (CPT) is required by most insurers. Procedure codes need to be routinely checked or validated against the diagnostic codes to assure reimbursement is made only for those procedures that are “medically necessary” for the treatment of the stated diagnosis. Either the coder or biller, depending on the facility, should validate the CPT codes for accuracy.

• Claims are processed to the insurer according to the terms set forth in the benefit plan. After receiving the claim, the plan may:

– Verify the patient’s coverage type

– Verify the services provided are covered

– Verify services meet Plan requirements

– Verify pre-certification was required and/or obtained.

• Billing must be familiar with the requirements, benefits, and exclusions for each insurer. AR must also follow-up on all rejected, unpaid, or denied claims within the stipulated timeframe for each insurer

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