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.
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Sample Solution
Medicare:
- Medicare is a Federal health insurance program for people over the age of 65 and those with certain disabilities.
- When billing Medicare, providers must use the CMS-1500 form, ICD-10-CM diagnosis coding system and CPT procedure codes.
- All procedures must be medically necessary and documented in the patient's medical record. Documented services must also adhere to coverage criteria as determined by Medicare.
- Inpatient services require preauthorization from Medicare before submitting bills to ensure that all service are medically necessary, as well as documentation that supports the need for inpatient care.
- Outpatient services do not typically require preauthorization but they may require prior authorization or notification if performed within 72 hours of an admission or discharge from an acute setting.