Billing specialists must take care to make sure insurance claims are reimbursed at the highest possible rate.
Every medical facility has billing guidelines specific to the practice. A billing specialist for an urgent care center should be kept up to date on general rules and guidelines of the practice so that maximum payment is received, within a minimal time frame. Billing errors are costly to the physician, the practice and the patients.
The Urgent Care Facility
According to the Urgent Care Association of America website, "Urgent care is defined as the delivery of ambulatory medical care outside of a hospital emergency department on a walk-in basis without a scheduled appointment. Urgent care centers treat many problems that can be seen in a primary care physician's office, but urgent care centers offer some services that are generally not available in primary care physician offices, for example: X-ray facilities allow for treatment of minor fractures and foreign bodies, such as nail gun injuries."
Billing Professionals
In her textbook about billing, Marie Moisio writes, "An insurance billing specialist can be described as an individual who processes health insurance claims in accordance with legal, professional, and insurance company guidelines and regulations." Since 70 percent to 80 percent of all medical bills are paid by an insurance carrier, according to her, it is imperative that billing professionals stay current in their knowledge of claims processing. An urgent care practice may want to hire someone with experience specific to urgent care centers, since some of the rules will be different than private practice or emergency room billing.
Proper Form
Since the urgent care facility is an outpatient setting, bills must be submitted using a form called CMS-1500. Formerly called the HCFA-1500, the CMS is subdivided into about 35 sections. Some of the information is very general. The billing specialist will have to fill in the patient’s name, address, social security number, marital status, etc. While these things are important for identifying the correct patient, there are some other sections that determine whether the bill gets paid, and at the highest possible reimbursement rate. These sections include number 21, the diagnosis section; number 24b, place of service (POS); and 24d, procedure code(s). Obviously, the CMS-1500 needs to be completed in its entirety, but these are the sections that can cause the most trouble.
ICD Coding
Coding the aforementioned sections is essential. An insurance form absolutely must contain a diagnosis. The diagnosis tells the insurance company why the patient was seen. A diagnosis code is a numeric, or an alphanumeric, sequence chosen from a book called International Classification of Diseases - 9th revision (ICD-9). For example, a diagnosis of eye pain corresponds to 379.91 in the ICD-9 book. It is this numeric code that must be entered on the form for proper processing. Each form has space for up to four diagnoses.
CPT Coding
The other necessary coding book is called Current Procedural Terminology. While ICD refers to why something was done, CPT refers to what was done. Procedures, too, correlate to a numeric code in the CPT book. For example, removing a foreign body from the eye would be coded as 65205. The CPT book also lists place of service codes from which to choose. An urgent care facility is a code 20. An hospital emergency room is a code 23. Entering the wrong POS code will cause the insurance company to reject the bill.
Medical Necessity
The CPT code and the ICD code combination must be plausible, or show medical necessity. It makes sense that a person came to an urgent care center with eye pain, then had a foreign body removed from the eye. If a billing specialist enters a diagnosis of eye pain, but uses the procedure code for a chest x-ray, this will be rejected. The insurance company will fail to see why a chest x-ray was needed for a painful eye.
Dealing with Rejection
If an insurance company rejects the claim, all is not lost. The insurance company usually provides the reason it did not pay. Rebilling the claim is usually an option. An experienced billing specialist should be familiar with the guidelines for dealing with rejected claims.
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