What Is Medical Billing?
Posted by
Ali Ziehm on Wed, Oct 19, 2011 @ 10:51 AM
Medical billing is the process through which medical, psychological and other healthcare providers submit claims for payment of services to insurance companies and patients. Claims are prepared using a set of diagnosis (ICD-9-CM—International Classification of Diseases, 9th Revision, Clinical Modification) and procedure (CPT—Correct Procedural Terminology) codes specified by the American Medical Association. Claims are generally transmitted to insurance carriers on a special form (HCFA 1500) or electronically, and insurance carriers use the claims to reimburse (pay) the provider or facility for services rendered to the patient on the date specified. These payments are issued to the providers or facilities according to a contracted fee schedule, which includes reimbursement according to terms set forth in a provider agreement entered into by both the provider or facility, and the insurance carrier. These rates vary from insurance carrier to insurance carrier, but are generally based on the rates of payment set forth in the WPS Medicare fee schedule, the list of rates paid by the Centers for Medicare and Medicaid Services (CMS) department of the US Government.
Codes are filled out on this form based on what procedures are done and codes can be found in procedure books put out by the AMA. The process of determining what codes to use for procedures and diagnoses is complicated and exacting, and generally requires specialized training.
