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Ask the Biller Archives


We started an Ask the Biller Archives. We had to move some of our older "Ask the Biller" questions to another page. It was just getting too big. Here are questions and answers from July 25, 2005 to May 15, 2007

Question for Ask the Biller:
May 15, 2007
The physician I work for in Washington state is not a participating provider with any insurance companies. We are a fee for service office. Why would he need a NPI number? I have had other offices call us to provide an NPI for him to be able to refer a patient to another doctor. They say that they cannot get paid by insurance unless they have my doctor’s NPI number.
Thanks in advance.
Charlyn



Response from Ask the Biller:
Hi Charlyn
They are correct. If your doctor refers any of his patients to another provider, they will need his NPI number to get reimbursed, depending on the insurance carrier of the patient. Eventually, all carriers will require it. So even though you are a fee-for-service office, other providers will not be able to accept referrals from you without an NPI number. They are free, and fairly easy to obtain. The application only takes about 15 – 20 minutes. You can fill out the application on line at:
NPI online application.

Michele

Question for Ask the Biller:
May 14, 2007
I only have 2 questions.
Iam a massage therapist.Do I need a NPI number and why?
As this is getting very frustrating.One person says yes and another says no.
Thanks
Alan T



Response from Ask the Biller:
Hi Alan,
There is still some confusion over whether certain providers need to have an NPI # or not, and LMT’s are one of them. If you contact the NPI enumerator they can’t even tell you. There is not a specific taxonomy code for LMT’s but they tell you to use the one that is under Other Taxonomy, then pick Specialist. If you are billing insurances then it is a good idea to have one, even though the NPI numbers are not required yet by Workers Comp or No-Fault. Bottom line, the NPI numbers are free, and it’s better to be safe than sorry. If I were you I would get one.

Here is the link for the online application:
NPI online application. 
We also offer the service of applying for you if you would like. We charge $29.95 for the service.  You can contact us by calling 1-800-490-4299 between 8AM - 4 PM EST Monday - Friday.
Good Luck,
Michele

Question for Ask the Biller:
May 14, 2007
Hi,
What box(s) should the NPI number go in?
Thank You.
Elly D



Response from Ask the Biller:
Hi Elly,
Where the NPI number goes depends on if you are using the old HCFA 1500 or the new CMS 1500.
On the new CMS 1500 form the NPI goes in box 24J, 32A & 33A.
On the old HCFA 1500, there isn’t a specific place on the form, but some insurance carriers are having providers put it in box 19.

Michele

Question for Ask the Biller:
May 10, 2007
I am very new to medical billing. When I get an EOB which doesn't pay, but applies the amount to the patient's deductible, what are the legalities of adjusting that bill for the patient? We charge a lower amount for cash patients, so the person who has insurance would be paying us more in this case. Is it legal to adjust this amount or do we need to charge the amount that the insurance applied to their deductible?
Thanks,
Kelly W.


Response from Ask the Biller:
Hi Kelly, Legally, a provider must bill a patient for any amount applied to his/her deductible and copay. It is usually spelled out in the provider’s contract with the insurance company. If an insurance company gets word that a provider is not billing patient’s for their deductibles, they can terminate the provider’s contract. However, there are some ways around it. Laws vary from state to state so I can’t speak for certain where you are located, but a provider can offer a discount if there is ‘financial hardship’. Michele

Question for Ask the Biller:
May 10, 2007
DEAR SIR OR MADAM:
I AM A PHYSICIAN WORKING FOR A NON-PROFIT CORPORATION. I DON'T BILL FOR ANY SERVICES MYSELF. THE CORPORATION GOT AN NPI NUMBER, BUT I DID NOT GET ONE. A PHARMACY CALLED TO GET MY NPI NUMBER TO FILL THE PRESCRIPTION. DO I NEED TO GET AN NPI NUMBER? IF I DO, DO I HAVE A CHOICE TO GET MY OWN OR DO I NEED TO GET ONE ASSOCIATED WITH THE EMPLOYER NUMBER, SUCH AS WITH MEDICAID? I DO PLAN ON DOING SOME PRIVATE PATIENTS IN THE FUTURE. DOES THAT MAKE A DIFFERENCE IN THE WAY TO APPROACH THIS?
SINCERELY,
JOSEPH L


Response from Ask the Biller:
Hi Dr. L
Even though you are not billing for any services yourself, you do need an NPI number as a referring Dr and as a prescribing Dr. They are free, and easy to obtain. You will definitely need one when you do see private patients to get reimbursed by insurance carriers. If you go to our website,
www.solutions-medical-billing.com and click on NPI number on the left side, then scroll down to the bottom, there is a direct link to the website’s online application. If you have trouble finding it, please let me know. If you do not want to complete the application, we offer a service to do the application for you for $29.95. It only takes us about 5 minutes to do, and you usually get your NPI number within 24-48 hours.
Michele

Question for Ask the Biller:
May 6, 2007
Hi Alice,
What is an easy way to register your NPI with hundreds of health insurance companies out there? Thanks.
Satish


Response from Ask the Biller:
Hi Satish,
Not sure there is an easy way. Start using the NPI# on your claims. Medicare will forward them to the crossover carriers. Some companies are asking you to log onto their website and report them. Make sure when you send your claims you use both the legacy numbers and the new NPI number. This should help.
Alice

Question for Ask the Biller:
May 3, 2007
We want to know how do we provide our NPI number to all the payers we bill medical claims.
Noemi M

Response from Ask the Biller:
Hi Noemi,
Each insurance carrier seems to be handling it differently. Some insurance carriers are requesting that you sign into their website and enter your NPI. Some are asking for your NPI when you call for claim status. A few are calling offices and asking for them. Some are sending letters asking you to fax back the info. If you get a request from a company for the NPI to be submitted in a certain way, we suggest you do that.

We applied for NPI numbers for all of the providers we work with and put them all on a spreadsheet. We then faxed the spreadsheet to all the major insurance carriers. A couple of companies have asked us to enter the NPI’s on their website.

When you file your insurance claims, make sure that you are submitting both the old legacy # and the NPI number. That will leave less room for error.
Alice

Question for Ask the Biller:
May 1, 2007
PLEASE EXPLAIN WHEN AN A3 AND OR A2 VALUE CODE SHOULD BE USED IN BLOCK 39 OF THE UB. MY MOTOR VEHICLE INSURANCE WHO WAS PRIMARY DENIED THE HOSPITAL BILL. THE HOSPITAL BILLED MY SECOND INSURANCE WITH A VALUE CODE A2 WITH TOTAL AMOUNT OF THE BILL. SHOULD THE HOSPITAL HAVE BILLED MY SECOND INSURANCE WITH VALUE CODE A3 OR A2 PLEASE ADVISE SO MY BILL CAN GET PAID.
THANKING YOU IN ADVANCE
ANNA M


Response from Ask the Biller:
Hi Anna,
The A2 Value Code is used to indicate the amount to be applied to the patient’s co-insurance for the indicated payor. This does not sound like the appropriate code for what you are describing. The A3 Value Code is used to indicate the amount estimated by the hospital to be paid by the indicated payor. This sounds like it might be the appropriate code for this situation. But my question is why is the motor vehicle insurance not paying the bill, and if they are not paying it for an appropriate reason, is the hospital attaching their reason for denial to the UB? I would think that would be more likely the reason that your secondary insurance company is denying the claims.
Good luck
Michele

Question for Ask the Biller:
May 1, 2007
Good Afternoon Alice,
My name is Lakisha S. I was looking at your website about Medical Billing and I am interested in starting a Medical Billing Business from home. At the present time, I am working for a Global Insurance company in Washington. I have worked in the Medical field for 10 years now. I am currently reviewing medical terminology as well as Medical Insurance information. However, I still have a few questions:
1. How do I market my business?
2. How do I gain the trust from Doctors?
3. What are the Doctors look for when they are searching for a biller?
4. How much can I expect to earn starting out?
5. How do I set up a contract between the Doctor and Myself?
I know that I have a lot of questions, it's just that I am 29 years old and my husband and I are looking to start a family very soon. As you know, the price for child care is ridiculous! I look forward to hearing from you and thanks for your help.
Lakisha

Response from Ask the Biller:
Hi Lakisha,
Congratulations on wanting to work from home while you start your family. This is what Michele did, too.

There are many ways to market yourself to doctors. In fact we wrote a manual about marketing to doctors. You can read about it here.
"12 Marketing Strategies to Grow Your Medical Billing Business". 

You will find this is the hardest part of getting your business started. You do have to gain the trust of the doctors and this isn’t always easy if they don’t know you. Generally speaking when the doctors are looking for a medical biller, they are looking for someone they can trust to collect all the money they deserve for their services. He or she is going to want to hire a person who is detail oriented and experienced. Your ten years experience in the medical field will help.

Unfortunately you can’t expect to earn a lot of money when first starting out. You need to be billing for some doctors before the money starts coming in. It took us awhile before we earned regular paychecks. We also wrote a book
“How to Start Your Own Successful Medical Billing Business” which would help to answer many of your questions.

Best of luck to you.
Alice

Question for Ask the Biller:
April 24, 2007
My wife had our baby and some routine tests were performed in the hospital.  The insurance company said they don't have a problem with the procedures, but that they will not pay because the claims were filed with "Modifier 26".  The pathology service said they can't file the claims without the modifier 26 or else it could be considered fraud. 
Any suggestions?
Raymond F


Response from Ask the Biller:
Hi Raymond,
The modifier 26 indicates that the provider, the pathology service, only performed part of the test (the professional part).  The provider that performed the other portion of the test (or the technical part) would bill with a "TC" modifier. 

So the pathology service is correct when they say they can't rebill it without the 26 modifier since they didn't perform the entire test. 

I've never seen an insurance company refuse to pay a service due to the 26 modifier.  Did you call the company yourself?  I would recommend that you call back and ask again.  It is unfortunate, but there are many insurance companies with phone representatives that really don't know what they are talking about.  My first instinct is that this is a bogus answer.  If you receive the same answer on the second call, I would ask them what your appeal rights are and I would file an appeal.  If they would pay a provider for the full test they certainly should pay for each component separately.

If you don't get anywhere with a phone call and your insurance is through an employer, I would recommend going to your human resources department.  They may be able to help you since they are the ones paying the insurance company.

Congratulations on the baby!
Good luck,
Michele

Question for Ask the Biller:
April 16, 2007
Do Ambulatory Surgical Facilities need a NPI?  Of course the doctors who perform surgery and anesthesia each have their own NPI but I want to make sure a facility doesn't need one.  Thanks for your help.
Nancy

Response from Ask the Biller:
Hi Nancy
Yes, the Ambulatory Surgery Center must apply for an NPI number also.  You would apply for a group NPI number for the Surgery Center.  If you bill for services in the name of the Ambulatory Surgery Center with the Center's tax id# then you must have a separate NPI number for that center.  Better safe than sorry.  It only takes a few minutes and is free.
Michele

Question for Ask the Biller:
April 16, 2007
I have been seeing a chiropractor since Nov of 2006.  My deductible with my insurance is $500 and after my deductible is met my insurance pays 70% and I am responsible for the 30%.  I have noticed that before my deductible was met my office visits would be $30.  Now that I have met my deductible they charge me anywhere between $75 and $95 per visit.  I have to pay 30% of this.  On the insurance statements I receive the chiropractor's office is only billing my insurance $30 for each and it states I owe the doc's office $9.  But I always end up paying around 428.50 to $35 per visit.  Is this legal?

Response from Ask the Biller:
Hi
Without seeing your eobs (statements from the insurance company) it's difficult to say what's going on here.  What you need to know is if the doctor is participating with your insurance.  If he does participate, he can only charge you what the insurance carrier allows.  If you have a good relationship with your chiropractor's office, go in and ask why you are being billed so much.  Ask them to explain it to you.  If they don't participate with your insurance, you may wish to go to a chiropractor who does participate.
Please let us know what you find out.  We may be able to help you further.
Alice

Question for Ask the Biller:
April 11, 2007
I recently took the CPC, CPC-H exams (last weekend).  I am positive I passed them.  My problem now is what to do with them.  I know I want to work form home but have  never worked in the field before.  Coding is what I want to do, but reading your website I am getting the impression that I need a more global knowledge and training in billing.  The school I attended for a year online was pretty specific to coding and very little about the actual billing process.  Would your book be of assistance to me in this endeavor - to primarily just code?  Does it show how to in detail what is needed to start a home based medical coding business.  A little direction in what direction I should go would be extremely helpful.  I am planning to also take the CCS and CCS-P Tests this June.  Thank you for your time and attention.
Glenn L.

Response from Ask the Biller:
Hi Glenn,
Congratulations on taking the courses and knowing you did well on the tests.  I don't know of any work at home jobs that only involve coding.  Hospitals and very large medical practices hire coders, but unfortunately I'm not aware of any at home coders.  Our book we offer "How to Start Your Own Successful Medical Billing Business" was written for all the people who come to us asking how to get their medical billing business started.  We write about what it actually takes to get a medical billing service going.  There's little about coding in our book.
Medical billing is much more involved than coding.  If you decide to go that way, you will need more education.  I don't want to discourage you as we started our business so my daughter could work from home while she raised her kids.  Our office is located on property at my home and we love it.
Good luck,
Alice

Question for Ask the Biller:
April 11, 2007
I need to know what Place of Service cods Anthem recognizes in box 24b.  I have sent claims in with "3" for office visit.  I have also sent some "11" for office visit.  Which place of service code should I be using?  Also, in field 33 where am I supposed to place my anthem id#?  I work for a general medical physician in Kentucky.
Shelly T


Response from Ask the Biller:
Hi Shelly,
The correct place of service code for services in the office is "11".  The "3" is a very old code that is no longer used.  Your Anthem ID# or Pin on the old HCFA form should go in box 33 at the bottom of the box where it says PIN.  On the new CMS 1500 forms it would go in the same box, but over to the right further in box 33b. 

We are now working on a video we will soon be offering on how to complete the new CMS 1500 forms.  Let us know if you would be interested.  We're going to offer them for general billing as well as medical specialties such as vision, mental health, physical therapy, surgery, chiropractic, etc. 
Michele 

Question for Ask the Biller:
April 5, 2007
We are about to use the new HCFA 1500 form.  In box 24 can the service be in the red line or must it be in the white line?
Sue


Response from Ask the Biller:
Hi Sue,
In box 24 the service should print on the white line.
Alice




Question for Ask the Biller:
April 4, 2007
I work for an internist in California who recently started visiting patients in board & care homes.  We have been getting paid by Medicare for codes 9932x and 9933x using place of service code 13, assisted living but rejected by MediCal.  What is the correct pos code - 33 (custodial care)?

Response from Ask the Biller:
Hi
I assume that MediCal is your Ca. Medicaid.  Each state has different requirements.  We have found that calling the company involved, in this case MediCal, and asking what they require will usually get you the right answer.
Alice

Question for Ask the Biller:
April 4, 2007

Is there a website to look up providers' NPI numbers?
Pam B

Response from Ask the Biller:
Hi Pam,
Sorry there is no website to look up NPI numbers.  It would probably be a security nightmare as far as confidentiality.
Alice

Question for Ask the Biller:
April 2, 2007

We don't want to use pre-printed HCFA 1500 forms and were wondering if we simply printed the identical information on a plain piece of paper (black and white) if that would be ok?

If this is ok, do we have to include the legal jargon on the back of the pre-printed HCFA 1500 forms on the forms we create?

Thanks for your help.
Nancy W.


Response from Ask the Biller:
Hi Nancy,
Many insurance companies scan paper claims.   When they scan them, the red print on the HCFA forms is important to the scanning  process.  When you print the form as well as the claim information and it is all in black and white, the forms will not scan properly and may be returned to you.  The legal jargon on the back is not important to the claim payment process so it wouldn't matter, but the red lines and boxes on the claim forms do matter.  Sorry I didn't have better news for you.
Alice

Question for Ask the Biller:
March 26, 2007
I hope you can help me.  We have always sent our UB92s for our Ambulatory Surgery Center on paper claims.  We are trying to convert to sending them electronically.  They are not being accepted by the clearing house because there is no condition code on the claim.  We have never put a condition code on the paper claims and have always received payment.  We are an ophthalmology practice that routinely bills for cataract surgeries.  I have purchased the Uniform Billing Editor and have reviewed the condition codes and do not see one that seems to apply to us.  Can you please help me?
Thanks,
Cindy

Response from Ask the Biller:
Hi Cindy,
I also looked at all the condition codes and don't see one applicable.  I have never personally been required to complete that field either on my paper claims or my electronics.  There must be a code that you can automatically put into the electronic claims to get them to go thru that actually won't affect the billing.  I would contact the support line for the clearing house that you are using and ask them.  Often there are requirements by the clearing house that the insurance carriers don't necessarily set.  They certainly should be able to tell you what you can use to get the claims thru.  Explain to them that you don't need a condition code on the claim and that there is no appropriate code that you can use.
There are obviously other providers that use the clearing house with the same issue and they must have a generic value you can enter.
Do you go directly to a clearing house or do you have a vendor?  If you have a vendor, you should contact them first.  They will be more helpful.  If you don't get anywhere, email me back with more specifics.  What state are you in?  What clearing house, etc.
Good luck,
Michele

Thanks so much for the information.  I feel so much better knowing that you also could not find an applicable condition code.  We are in the state of Georgia and our software vender uses Mckesson as the clearing house.  I will have our software vendor contact the clearing house for this information.
Thanks so much,
Cindy

Question for Ask the Biller:
March 26, 2007
How do I know whether to use UB form (UB92) or HCFA/CMS form? 
Many thanks,
Satish

Response from Ask the Biller:
Hi Satish,
Usually the insurance carrier determines whether you need to bill on a UB or a HCFA by how they have you classified in their provider file.  Hospitals and facilities generally bill on UB92 (UB04s now).  Physicians bill on HCFAs (CMSs now).  When we bill for a facility, we call each insurance company and get the provider representative and ask which form they want us to bill on.  Generally it is the UB, but a few have told us to use the HCFA.  You can call each company and explain your situation and ask them which form they prefer.  I hope this helps you.
Alice


Question for Ask the Biller:
March 22, 2007
I just signed up today for your newsletter and already I have a question for you. 

We billed an insurance company for a patient that had services twice in the same day for different diagnosis.  Is there a modifier that we can append to the claim to notify the insurance carrier that this claim is a separate claim?
Thanks,
Sandy H

Response from Ask the Biller:
Hi Sandy,
I need a little more information before I can reply to your question.  What are the services the patient received?  Are you billing the same insurance for all services?  For example, you can't bill the same insurance for 2 E&M codes on the same day unless the patient returned to the office later on the same day.  But if the patient has a workers' comp case and you are seeing the patient for the work injury and other unrelated reasons, then you can bill an office visit to both insurances.  However, if the patient had an office visit for bronchitis and had incision and drainage for a cyst, then you can bill both services using the appropriate diagnosis with each claim line and using a 25 modifier on the office visit line to indicate the office visit was "separately identifiable E&M service by the same physician on the dame day".  There is another modifier, 59 which states "Distinct Procedural Service."

If none of these examples pertains to your situation, email me with more specifics! 
Hope this helps.
Michele

Question for Ask the Biller:
March 10, 2007
I was wondering if there is a page that I can access to obtain NPI numbers for physicians.  I work at St Margaret Mercy Health Care Centers and we are currently working to obtain all the NPI numbers for our physicians.  We are finding that when we call the physician's offices that they request for us to send a letterhead with our request.  This can be quite time consuming.  I was looking for an easier way.  If you could please assist with this matter I would greatly appreciate it.
Cheri M

Response from Ask the Biller:
Hi Cheri,
Because NPI numbers are confidential information, we are unable to obtain someone else's NPI number without asking them directly for it.  We've found the best way to handle this need for the individual NPI number is to write a form letter asking for the NPI number on your letterhead.  You can even briefly explain the need for it so the doctor’s office staff is more likely to act quickly on it.  These can be photocopied or printed out on the letterhead and a copy sent to each of the doctors.  You can also store the form letter in a word processing program in your computer and quickly type in the name and address of each provider if you feel there is a need to make it more personal. 
If your biggest concern is saving time I recommend photocopying the form letter on your letterhead and having a stack of them ready to send as you need them. 
Hope this helps.
Alice

Question for Ask the Biller:
March 6, 2007
Do you need a NPI number if you are not a Medicare provider and do not accept insurance?  Will you need it to order lab work?
Thanks,
Bob G

Response from Ask the Biller:
Hi Bob,
I would suggest that even if you are not a Medicare provider or even a provider who accepts insurance to obtain a NPI number anyway for a couple of reasons. 
1.  The law states that ALL health care providers must obtain a NPI number.  The penalty for not getting one is non payment of claims which will not affect a provider who does not accept insurances,  but the law states you must have one.
2.  They are free and relatively easy to obtain.
The lack of a NPI number most likely will interfere with other activities that the provider does, such as ordering lab work or referring a patient to another provider/specialist.  You can get to the application form at
NPI Number  at the bottom of the NPI page.
Michele

Question for Ask the Biller:
March 5, 2007
I am quite excited to find you.  My husband is a Chiropractor in Pa.  We use HCFA and now CMS 1500 forms.  Our software is Medisoft.  I cannot get the answer to many questions I have.  Which NPI number goes where?  We have one for group  and one for individual.  I believe this is box 33 on the new form.
Big question - I work for a durable medical equipment company that only submits to auto and workers comp.  Does this provider need an NPI?  They are not a dr and it is all paper - no health insurance.
Thanks so much for your help.
Marcy M

Response from Ask the Biller:
The group NPI number goes in box 32A and the individual NPI number goes in box 33A. 
Yes, the DME company should apply for an NPI number also.  Even though they aren't a Dr., they are a health care provider.  Many of the WC and NF companies may not be indicating that they require the NPI number to continue reimbursing, but as the law states, all health care provider's are required to obtain a NPI number.
Since there is no cost involved in getting one, I would strongly recommend that they get an NPI number asap.  There is no downside to getting one and a big downside to NOT getting one and then needing it!!
Thanks and good luck,
Michele

Question for Ask the Biller:
February 27, 2007
Hello,
As of 2007, we have been receiving denials from United Healthcare for CPT codes 97010 (Hot Packs) and 97014 (Unattended Electrical Stimulation).  They are telling us that these are bundled services.  I can't find any information as to which CPT code they should be bundled with.  The only other charge we do per visit is the Spinal Manipulation code of 98940.  Do you happen to know the answer to this?  All the above services are provided by a licensed Chiropractor.  There is not a Physical Therapist on staff.  We have never had a problem up until this year.
Thank you in advance for your help!
Rebecca

Response from Ask the Biller:
Our providers are not having any problem with UHC processing their claims for 2007.  They are not "bundling" the 97010 or the 97014 in with anything.  We do work with other insurance companies that bundle these two codes in with the manipulation code but that is because they have a "global fee" for chiropractors. 
The other thought that I had was - are the UHC plans that are denying codes in specific groups?  Or is it all UHC across the board?  We have a large UHC plan here called Empire, but it is processed by UHC.  They have their own set of rules and don't have to go by UHC rules.
Have you tried to call UHC and ask why the claims are being processed differently?  If you have a specific patient that had a visit in 2006 and in 2007 that were processed differently, I would call and ask someone to explain it to you.  You might even want to contact your UHC provider rep for your area.  They may be able to help.  It may be a problem with their processing system that needs to be addressed.
Good luck.
Michele

Question for Ask the Biller:
February 26, 2007
Is there any way we could get a few samples of the new UB04 form?
Robin

Response from Ask the Biller:

Hi Robin,
I don't have any of the UB04's yet myself.  I'd be glad to send you a few.  We've been sending all our UB04's electronically so I haven't had to purchase any forms yet.  But you can find a form and instructions at this link.
http://www.ibx.com/pdfs/providers/npi/ub04_form.pdf
Alice

Question for Ask the Biller:
February 15, 2007
I need help with UB92 claim forms.  I am new to the psychology field.  I have been sending UB92 claim forms to Blue Cross of California and I keep getting the following comments sent back, "please resubmit claim with correct type of bill."  I have been using 131 - not sure if that is correct.  The codes we use for billing are "0913 for adult/child disorder full partial day" and the other code is "913 Psych/Partial Intensive."  912 Psych Partial Hosp/PHP.  I have called and spoke directly to a supervisor and she mentioned that she did not see a problem. The other thing I found out was that 131 each number gives three specific pieces of information.  The first digit of the 3 denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the sequence of this bill for a specific episode of care...  Not sure where I could get a list of definitions and guidelines for this problem I am having...?
Ester

Response from Ask the Biller:
Dear Ester,
You are correct with the information that you have regarding the 3 digits of the type of bill field. Do you have access to a UB92 Editor (book)?  It would be very helpful to you in this situation.  It breaks down the UB92 by field and explains each in detail.  Based on what you told me in your email it looks like your type of bill, 131 is indicating hospital (1st digit) outpatient (2nd digit), admit-through-discharge claim (3rd digit).  I can't quite tell by the information that you gave me if that is accurate, but if it is not, please email me back with more specifics and also which portion you feel is not accurate.  I can try to help you find the right code.
Michele

Question for Ask the Biller:
February 15, 2007
I just received my new preprinted HCFA 1500 forms and on "24C Type of Service" has been replaced with emg.  What is emg and what do I put there?  I can't find this info anywhere.
Thank you soooo much

J Wells

Response from Ask the Biller:
Dear J Wells,
On the new CMS 1500 forms they no longer have a field for the type of service.  There is no longer a need to indicate the type of service at the claim level.  The EMG field that replaced it is only if the service is related to whether or not it was an Emergency.  Most insurance companies do not require this field to be completed and it should be left blank.  This field was already on the old HCFA 1500, but it was box 24I.  If you weren't using it before, you don't need to worry about it now.  Just leave it blank!
Hope that is helpful.
Alice

Question for Ask the Biller:
January 25, 2007
What fields do I need to fill out on a UB92 for Home Health?  Also, I am looking into becoming a certified coder for all specialties.  Who offers this in Virginia?  Can I take this course online? 
Thank you.
Sharon B.

Response from Ask the Biller:
Dear Sharon,
The required fields on the UB92 vary from insurance carrier to carrier.  I can recommend a great resource for you which will detail field by field the requirements for your specialty.  It is the UB92 Editor and can be purchased from Ingenix at
http://ingenix.com    
I did a quick search and it does look like you can become a certified coder with an online course.  I did a Google search for "certified coding specialist Va" and several options came up.  I would suggest that you look into them to see what is best for your circumstances.
Good luck,
Alice
 
Question for Ask the Biller:
January 02,2007
Dear Alice,
You have helped me once before with the UB92 form and I hope you can answer another question.  One of our insurance companies is not accepting 049x (ambulatory surgical care) in box 42.  I have reviewed the other choices listed in the manual and also from information listed on the Empire Medicare Website and the 049x appears to be our best choice.
We have been accredited as an Ambulatory Surgical Facility and therefore 049x seems very appropriate.  I would appreciate your help.  Thank you,
Nancy O


Response from Ask the Biller:
Dear Nancy,
If the 049x is the best choice for your facility and the other insurances are accepting it, I would recommend contacting the company that is not accepting it and speaking to your provider representative.  (Most of the larger insurance companies have a designated provider rep for the doctors to contact with problems.)  They should be able to help you out with
1.)  Why do they not accept the 049x (which is accepted by most others)?
2.)  What will they accept that still describes your facility?

Each insurance company has different claims processing systems and this company may need to change their system to allow for the 049x code.  Bringing it to the attention of the provider rep may help straighten it out.
Hope this helps.
Alice

Question for Ask the Biller:
December 19, 2006
Hi,
I went to my general physician and had a full battery of blood tests back in May because I had a rash or an allergic reaction. I also had not had a blood test for years. Anyway, the results showed that I had Hypothyroidism. My GP wanted to put me on Synthroid but I felt that I should see a specialist (Endocrinologist). I went to the Endocrinologist with my blood results and he also stated that I would need to be put on Synthroid. I decided at this point that I will follow his conclusion and I started taking medication. Several months later, I went for more blood tests to see how my levels looked. I also thought that I would go to another Endocrinologist for a second opinion, who was also closer to where I live. Not to mention I was not thrilled with the first Endocrinologist. I went to the second End. with recent blood work and she reviewed it and suggested that the amount of Synthroid needed to be lowered. She wrote me a prescription and a filled it. I set an appointment for a follow-up visit with her to check my levels again. A day before my scheduled visit, my Explanation of Benefits came from my insurance company. I owed $350.00 for the "Consultation" that the 2nd Endocrinologist gave me. I called the insurance company, United Health Care in New York, and they explained that my plan only covers one consultation per year, per specialized area for the same issue. I tried to explain to the insurance co. that this was a second opinion but they said that the Dr. billed it as a consultation. I went to my appointment with the Dr. and talked to them about the bill. I explained to the billing manager that the previous visit was a second opinion and that the insurance company said they would pay for it if it were billed that way. The billing manager got nasty and told me that they cannot change how it was billed to the insurance company because it would be fraud. Now I am responsible for paying $350.00 because of what I believe was a clerical error on the Dr.'s part. What do I do?? What is the difference between a consultation, a second opinion and an office visit? Should I pay the Dr. of try to fight this? I don't want this going to collections.


Response from Ask the Biller:
Hi, This is a messy situation. It is true that UHC doesn’t cover more than one consultation per year for a specialty. As far as the billing manager getting nasty, that’s unfortunate. It isn’t fraud to change what was billed to an insurance company if the original billing was incorrect. I personally don’t understand why when you make an appointment to see a new doctor who is a specialist it gets billed as a consultation as opposed to a new patient exam. If the service was billed as a new patient exam, UHC would have paid it. However, the allowance for a consultation is considerably higher than it is for a new patient exam, which makes it clearer as to why the provider bills it that way. Unfortunately, it is up to the doctor to decide what service(s) they performed while with the patient. So you really don’t have many options. If the billing manager states that the service(s) were billed appropriately, then you cannot force her to change them. However, she should be willing to work out something with you if she had any hopes of you being a return patient. I’m not sure if you want to continue seeing the doctor, but if you did, you may want to bring it up directly to her. She may be interested to know how her billing manager is treating her patients. Many times the doctors have no idea what is happening on the business end, and they should. They never know that a patient left because of dealings with their staff. I wish I could be more helpful, but your options are limited. You may be responsible to pay the whole amount. Good luck. Alice  

Question for Ask the Biller:
November 9, 2006
Hi my name is Cindy and we have had the same insurance and used the same provider for the past 4 years.  Until recently we haven't had any billing problems.  However, in the past month we have had 4 claims rejected by our insurance company because the doctor we supposedly saw was not a contracted provider with the insurance company.

We check in first and they accept our insurance and take our copay.  We are then seen by the doctor.  One would assume that we should not have to ask if that particular doctor is a contracted provider with our insurance company.  Well, come to find out, the doctor's office is using one doctor's name to bill the insurance company regardless of which doctor has been seen.  The name of this doctor just happens to be the doctor not covered by our insurance.  Is this legal?

My insurance company tells me that the claim they receive from the doctor's office is a legally binding contract and therefore they cannot change it.  Thank you in advance to your response in this matter.  I am seriously thinking about talking to a lawyer about this issue.

Cindy

Response from Ask the Biller:
Hi Cindy,
We have been advised by many insurance company representatives that it is illegal for a doctor to bill for services performed by another doctor.  It sounds as if the provider is not billing correctly.  I would think that your insurance company would have a problem with the fact that your doctor sent them a "legally binding contract" that is not accurate. 
I would start with your doctor's office.  First of all, do they have any signs stating that they are participating providers with your insurance?  Did they ever advise you that they didn't participate?  If they accept your insurance then they cannot legally charge you for these services above the amount of your copay.  If they have been accepting your insurance right along and they stopped, you should have been notified that they were no longer accepting it.

Ask to talk to the billing manager.  You need to calmly explain that your understanding is that the office accepts your insurance.  If you absolutely can't get anywhere with the office staff you need to contact your insurance company and explain that you feel your doctor's office is billing your insurance incorrectly.  Tell the representative which doctor it was who treated you.  You are probably not the only patient with this problem and the office staff needs to address it and fix the problem.

A lawyer would probably be an expensive way to go.  If you don't get anywhere with these suggestions, let us know.

Good luck,
Alice

Question for Ask the Biller:
October 4, 2006

Do you know the location the NPI# goes in on the UB92?
Paula L Chester County Healthcare Inc

Response from Ask the Biller:

The current UB92 does not have a specific location for the NPI# so it will become obsolete in 2007. As of January 1, 2007 we will be able to submit on the new replacement for the UB92 called the UB04.  The UB92s will no longer be accepted after April 2, 2007.  Make sure your software and vendor can accommodate this change.
Alice 

Here's more information on the change from the UB92 to the UB04.

Question for Ask the Biller:
October 2, 2006

I have a question about the UB92 form, revenue code box 42. We are an accredited ambulatory surgery center so I have been using 049X as the revenue code. Please let me know if this is the correct code.

Where could I find type of service codes for our HCFA 1500 forms? I found the most recent place of service codes in our CPT4 book but there is no mention of type of service codes. Thanks for your help.
Nancy O

Response from Ask the Biller:
On your question on the UB92 forms, my experience has been that they vary between insurance carriers. We call each insurance company and ask which rev codes were appropriate to our situation. They were very helpful. If they are paying with the 049X, it must be correct.

We found a chart of the type of service codes at the Blue Cross website. I would provide a link, but it is a secure site with a sign in. If there is a particular code you need and can't find the chart, let me know and I'll look it up for you.
Alice

Question for Ask the Biller:
October 10, 2006

Hi Alice,
Thanks very much for the information. We are not participating with BC so I cannot sign in. I would like to find out the type of service codes for Consultation, Surgery, Anesthesia, and Facility.
Nancy O

Response from Ask the Biller:

Hi Nancy,

I just checked the BC website and Anesthesia is 7, Consultation is 3, Surgery is 2, and Facility for ambulatory surgery is F. Glad we could be of help.
Alice

Response from Ask the Biller:

Question for Ask the Biller:
September 25, 2006


Question for Ask the Biller:
September 19, 2006

I was wondering if there is any way of finding out the UB92 code that was sent from the hospital to the insurance company. I am having a problem with the bill from the insurance agency not paying their portion of the bill. They state that the patient did not pass away with cancer although this is listed on the death certificate. The patient, my aunt, also carried a cancer policy with the insurance agency. I need to find out the UB code that the hospital sent to the insurance agency. Can you give me some advice please? I appreciate any information you may give.

Thank you - DD


Response from Ask the Biller:
First you need to call the hospital billing department and tell them that your insurance company is denying your claim due to the diagnosis code submitted. You need to know if they used a cancer diagnosis when they submitted the UB92 to the insurance company. If they did not use a cancer diagnosis, you need to ask why not. You should also call your aunt's insurance company (the number is on the back of her insurance card) and ask specifically why they did not pay this portion of the bill. The representative may help you determine what else needs to be done. Let me know if this helps or you need further assistance.
Alice

Question for Ask the Biller:
September 1, 2006

Do I have to purchase claim billing software or could I just set up with a clearing house? I'm just starting out.

Lee G

Response from Ask the Biller:

You must have practice management software to send the information to the clearing house. That's how the clearing house gets the information.

Alice

Question for Ask The Biller:
September 1, 2006

Alice

Question for Ask The Biller:

August 25, 2006
Question for Ask the Biller

August 5, 2006

I received a bill from a Radiology Group for $300 for a mammogram. They said my insurance company won't pay for it. Do I have to pay this bill?

Jeanette T.


Response from Ask The Biller:
Most insurance covers mammograms whether they are routine or for a medical condition. In either case, you should contact your insurance company and ask them why they didn't cover the charges. It may be an error on their part, or the provider may not have billed the charges correctly. If you have a deductible, the charges may have been applied to that and you may be responsible. The phone number for your insurance company should be on your insurance card.

Michele

Response to Advice from Ask the Biller:

Thank you so much for your advice. I called my insurance company and they said that the charges were denied incorrectly. They are reprocessing my claim and paying the bill in full! I'm so glad I didn't pay it myself! Thanks again.

Jeanette T.

Question for Ask The Biller
July 25, 2006

I had to deal with a service that missed submitting a bill of mine and because it was past the maximum time (in their contract) the insurer refused payment. The billing service tried to bill me for the entire bill. It was eventually turned over to a collection agency. After three separate calls from my insurer, that bill was not billed to me and the billing company actually returned $32.00 that I had over paid on another charge. I haven't checked, but guess I'd better, make sure they didn't report me to one of the credit bureaus as I was recently turned down for credit and have an excellent credit rating and have almost no credit card debt.

I can't help but wonder how many other people had to put up with dunning letters and phone calls. The caller from the collection agency was very kind but I am sure he did not believe me as most businesses would not turn over a bogus debt to collection.

Bonnie B

Response from Ask The Biller:
The email is accurate and it is an EXCELLENT example of a POOR billing service. The billing service should not have billed that patient. If they missed sending in her claim to the insurance company in a timely manner then they should have been answering to the Dr as to why! If the Dr is contracted with her insurance company it is ILLEGAL for them to bill the patient because they missed the time filing limit.

Michele

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