Section VII: Billing, Coding, & Insurance

HMO (Health Maintenance Org)

Requires referrals and a primary care provider (PCP); lower cost

PPO (Preferred Provider Org)

No referral needed; higher premium but more flexibility

Medicare

Federal program for adults 65+, disabled individuals, or ESRD patients

Medicaid

State and federally funded; income-based

TRICARE

Insurance for active military and their families

CHAMPVA

For veterans’ spouses and dependents

Workers’ Compensation

Covers injuries that occur on the job

Self-Pay

No insurance; patient pays out-of-pocket

ICD-10

• The diagnosis (why the patient is being seen)

• 3–7 characters, always starts with a letter

• Ex: J45.909 = Asthma, unspecified

CPT

• The procedure or service performed

• Always 5 digits, no letters

• Ex: 36415 = Blood draw

E/M (Evaluation & Management) Codes

• Found in the CPT code set

• Always start with 99*

• Used for documenting office visits, consults, and assessments

99213

Established patient office visit

36415

Venipuncture (blood draw)

81002

Urinalysis (non-automated)

90471

Vaccine administration (first shot)

87880

Rapid strep test

J3420

B12 injection (J-codes = meds)

CMS-1500

The CMS-1500 is the universal claim form for outpatient care.

Includes:

• Patient demographics

• Insurance info

• ICD-10 & CPT codes

• NPI (provider number)

• Diagnosis pointers

• Signature and date

Clean Claim

Accurate, complete, processed without issues

Rejected Claim

Contains errors and needs correction before payment

Denied Claim

Insurance refuses to pay (e.g., not covered, no prior auth) (appeal)

Referral

PCP sends patient to specialist (required by HMO)

Prior Authorization:

Insurance pre-approval before service or medication

Eligibility Verification

MA confirms patient’s insurance is active and covers service

Common Billing Errors

• Wrong patient info

• Incorrect ICD/CPT pairing

• Missing provider signature or NPI

• Service wasn’t documented

• No insurance verification

• Duplicate billing

• Modifier missing when required