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General Questions / Re: Facility OR Charges Separated into Multiple Procedure Codes
« Last post by Michele on April 16, 2021, 07:25:26 PM »
No question is too basic!  But before I can answer I have to ask a couple questions:

Are you billing for the facility or the surgeon? 

Are you questioning the amount billed?  Or how they broke it down?

I have to know the answer to the first question in order to respond.  I'm asking the second question because I'm wondering why the billing service would be determining the amount to charge.  :)
First, let me apologize for asking such a basic question.  I know very little about medical billing and coding, but somehow I have become responsible for overseeing our third party medical billing company.  The hospital CEO recently saw some charges for an ortho surgery and wanted to know how they came up with the charges for each CPT code billed. 

The response was that billing takes the total OR charges for the procedures only (not including anesthesia, supplies etc), divides it in half, and assigns that half to the first CPT code they are given (I assume this means the primary procedure).  The other half gets divided among the remaining procedures.  For example:

Total OR Charges: $30,000

23430  billed at $15,000 (First Code)

29824  billed at $3,750

29823  billed at $3,750

29826  billed at $3,750

64415 billed at  $3,750

Is this best practice? It seems strange to me.  But then again, I don't know anything.
New! / Re: What are the steps in the medical billing process?
« Last post by Michele on April 16, 2021, 07:04:27 AM »
* Patient Registration
* Establishment of financial responsibility for the visit
* Patient check-in and check-out
* Checking for coding and billing compliance
* Preparing Claims
* Transmitting claims
* Monitoring payer adjudication
* Working aging reports
* Posting Payments
* Handling denials/appeals
* Generating patient statements or bills
* Arranging collections
New! / What are the steps in the medical billing process?
« Last post by alicecarlosmbc on April 16, 2021, 02:09:20 AM »
New! / Re: Does Medicare cover DSMT Benefit?
« Last post by Michele on April 15, 2021, 07:36:12 AM »
Medicare Part B (Medical Insurance) covers outpatient diabetes self-management training (DSMT) if you've been diagnosed with diabetes. Medicare may cover up to 10 hours of initial DSMT 1 hour of individual training and 9 hours of group training.
New! / Does Medicare cover DSMT Benefit?
« Last post by alicecarlosmbc on April 15, 2021, 01:50:21 AM »
New! / Re: how to calculate medicare free schedule rate
« Last post by alicecarlosmbc on April 15, 2021, 01:47:48 AM »
Thanks Richard
New! / Re: The age old question of how to set fees for your Billing Service
« Last post by medwave on April 14, 2021, 09:21:49 PM »
Hi Everybody!

As a medical billing service, I was asked recently what my charge would be "per claim" and I hadn't heard this term in a verrrrry long time!  I reached out to Linda Walker and Merry Schiff who both gave me some insight but I wondered how others in the field might respond to a request like that.

It's a different concept that was used back in the day when an office might only want someone to enter their claims and submit claim electronically.  I believe it was popular when most offices didn't use computers but wanted the quick turn-around for their reimbursement.  Crazy to believe, but that was only in the last 20 years or so! 

Now that pretty much everyone has a system in place, a "per claim" fee is hard to determine because you have to consider what is involved.  I came up with the following levels and wondered if anyone would like to offer their opinion on what you would charge for each level, and if you think other items should be listed or taken out.

TIER 1: CLAIMS PROCESSING   _____ per claim
   Submission of primary, secondary or tertiary commercial claims with required attachments when needed. (Each claim is charged individually)
   Submission of Workers Compensation claims and No Fault claims
   Posting patient and insurance payments for all claims filed
Analyze explanation of benefits statements from insurance companies and verify accuracy of payments. 
   Notification to the office when claim(s) are determined to be rejected, denied or paid inaccurately.
   Claim status review for all claims 35 days past submission date.  (Refiled claims are handled as a new claim submission)
Monthly Patient Statements printed and mailed, office handles patient phone calls

TIER 2: PRACTICE MANAGEMENT    _______ per claim
   All services as listed in TIER 1
   Toll-Free number and secure, encrypted email for patients use regarding any and all questions pertaining to billing.
   Monthly report of claims submitted, payments and adjustments applied.
   Quarterly review and report of Revenue Cycle Management Process
   Review and correction of billing errors when claims are rejected, denied or paid inaccurately and/or query to doctor for additional assistance when needed.

   All services as listed in both TIER 1 and TIER 2
   Certified Coder review of records to verify documentation supports claim, query to physician when addendum is warranted.
   Customized design of coding and billing forms and reports.
   Yearly Fee Schedule Review with Coding Updates
   Monthly Eyecare Professional Newsletter with billing, coding and marketing tips
   Discounted rate for subscription to
   2015 ICD-10-CM Update to System and applicable forms (Training available separately)

   Service available separately or in addition to any of the Tiers listed above. Current demographic and insurance information must be provided.
   Active coverage is verified online, and then a live call is made to the carrier to obtain details of patient coverage including patient and/or family deductible, out-of-pocket expenses, material allowances and eligibility.
   Completed EB Form will be sent back to the office prior to the patients scheduled appointment.  Copy should be given to patient when they check-in so they are aware of the full expected payment at check-out.
   Office will be notified immediately for patients who are found to be ineligible for have terminated coverage so other arrangements can be made or appointment cancelled.

I'm looking forward to seeing what everyone thinks, but please include how long you have been "in the business" with your post.  I think it makes a difference and hope to keep this topic informative and helpful.  :)  Thank so much and have an amazing day!

New! / Re: how to calculate medicare free schedule rate
« Last post by RichardP on April 14, 2021, 07:40:34 PM »
There is no such thing as a Medicare Free Schedule rate.

There is only a Medicare Fee Schedule.

That Fee Schedule is available from your MAC.  See Point #3 at this link:

Or maybe you are asking about this:
New! / how to calculate medicare free schedule rate
« Last post by alicecarlosmbc on April 14, 2021, 01:07:39 PM »
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