unit 10 hstp

Encounter Form (Superbill)

Includes patient name, provider, date of service, diagnostic code, and services provided to ensure correct reimbursement.

837P / CMS-1500 Form

Required form used to bill third-party payers for outpatient medical services.

Advanced Beneficiary Notice (ABN)

Notifies Medicare patients that a service may not be covered, allowing them to accept or decline financial responsibility.

Preauthorization

Approval from insurance confirming a service is medically necessary and will be covered.

Services Requiring Preauthorization

Surgeries, radiology tests, hospitalizations (e.g., endoscopy).

Services NOT Requiring Preauthorization

PFTs, EKGs, urinalysis.

Emergency Services & Preauthorization

Providers may proceed without preauthorization; appeals can be submitted if denied.

Medical Necessity Documentation

Chart records must justify services provided to avoid claim denial.

Handling Patient Billing Complaints

Refer patients to the claims specialist for proper assistance.

CPT Codes

Codes describing medical, surgical, and diagnostic procedures on claims.

Outpatient Diagnosis Coding Rule

Use confirmed diagnoses (e.g., “fever of unknown origin”); avoid terms like “rule out” or “suspected.”

Billing Code Requirement

All codes must be supported by documentation for reimbursement.

Medicare Part A

Covers hospital services.

Medicare Part B

Covers outpatient care and durable medical equipment.

Medicare Part C (Medicare Advantage)

Combines Parts A and B through private insurance.

Medicare Part D

Covers prescription drugs.

Release of Information Form

Signed at check-in to allow sharing of medical info with insurance.

Preauthorization Expiration

Services after expiration may result in claim denial.

Reconciliation

Matching clinic financial records with bank statements.

Posting Payments

Recording received payments to maintain accurate financial records.

Credit Adjustments

Posted at the same time as payments.

Endorsing a Check

Signing one’s name on a check.

Cycle Billing

Sending bills on a rotating schedule (e.g., by last name groups).

Medicare Electronic Claims Exception

Single-provider practices are exempt.

Birthday Rule

For children with dual insurance, the parent with the earlier birth month provides primary coverage.

Usual, Customary, and Reasonable (UCR)

Standard fees charged by similar providers in the same region.

Abstracting

Reviewing medical records to assign correct diagnosis and procedure codes.

Auditing a Claim

Checking if a claim is complete.

Reviewing a Claim

Verifying correct diagnosis and procedure codes.

Unbundling

Separating procedures into individual billing codes (often improper).

ICD-10-CM Coding

Use the Alphabetical Index to find diagnosis codes.

Incorrect/Outdated Codes

Can lead to reduced or denied reimbursement.