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Medical Billing

In order to properly code a bill for medical necessity, it is important to understand different plans and the requirements for billing each. It is true that they all use the ICD-10-CM diagnosis coding system, the CPT procedure coding system, and the CMS-1500 form, but each type of carrier has certain requirements for a clean bill.

Tasks:
Create a billing manual constructed of summaries of each type of insurance.
Include the major requirements for billing for each type.
Note inpatient or outpatient differences where appropriate.
Explain how to determine from the patient which type they subscribe to.

Sample Solution

1. Medicare: Medicare is a government health insurance program for people 65 years of age or older, as well as certain disabled individuals. To bill Medicare, you must use the HCPCS code set and the ICD-10-CM diagnosis coding system. You will also need to provide reason codes that explain why the services are medically necessary and document this in patient charts with appropriate encounter forms. The CMS 1500 form is required for billing Medicare.

2. Medicaid: Medicaid is a state administered health insurance program for people who meet specific income thresholds and needs based criteria established by each state’s Medicaid agency office. To bill Medicaid, you must use the ICD-10-CM diagnosis coding system, CPT procedure codes and include any relevant modifiers to indicate delivery type or other circumstances impacting services provided such as emergency care or hospitalizations.. Documentation requirements include proper completion of all claim forms (CMS 1500) plus additional documentation that meets state standards including signed consent forms, proof of guardianship if applicable and preauthorization documents (if required).

The year of 1976, US observes Bicentennial. Popular Front for the Liberation of Palestine guerrilla’s highjack airline at Entebbe, Uganda. Riots break out in Soweto, South Africa. Gases from spray cans reported to damage the ozone layer. Exercise clothing and Lycra leotards become a new fad. Clothing and textile manufacturing in developing countries expands. Authors of Fashion in the ‘70s: The Definitive Sourcebook, Emmmanuelle Dirix and Charlotte Fiell state that, “The Seventies evidenced a wide range of fashionable hairstyles and makeup trends”, and 1976 was when the big hair was at its peak (Dirix and Fiell 27). The year of 1977, Baader-Meinhof terrorist’s highjack plane in Somalia. New York-London begins passenger service on Concorde jet. Elvis Presley dies. Safety pins, ripped and torn second-hand clothes, plastic, and leather are what is big in fashion. Barry Miles writes, in the book Hippie, “Girls looked for old-fashioned, second-hand dresses in thrift stores, favouring worn, soft fabrics like lace and velvet and often opting for long granny dresses. If they felt like dressing up then anything went – handmade clothes often tie-dyed in earth colours of psychedelic rainbows, hand strung beads and, if the climate was temperate as in California, bare feet. Maybe even flowers in their hair” (Miles 18). This is the year Saturday Night Fever was released. Marie Claire wrote, “…and the world fell head-over-heels in love with disco. John Travolta’s car-salesman suit and Karen Lynn Gorney’s major commitment to ruffles had everyone reaching for their platforms and dancing their troubles away. Nothing quite says seventies like a disco dancefloor, am I right?” (Leaper). Disco was a huge hit throughout the era as well as disco and hippies went hand in hand with their fashions. The year of 1978, diplomatic relations opened between the US and People’s Republic of China. World’s first test tube baby is born. Marathon running turns into big public events. Tailored coats, unconstructed jackets and padded shoulders came in, in women’s fashion, “Women on both sides of the Atlantic worked outside the home, a more practical yet stylish style of dress was needed…The tailored trouser suit was a response to this need and search” (Dirix and Fiell 27).>

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