Lucky Luciano's Insurance: Chapter 11 Cms-1500

Physicians services for inpatient care are billed on a fee-for-service basis, meaning that physicians are paid for each specific service or procedure they provide. To ensure accurate payment, physicians submit CPT/HCPCS level II codes to payers. These codes provide a standardized way to describe the services and procedures performed, allowing payers to determine the appropriate reimbursement amount. The CPT/HCPCS level II coding system is widely used in the United States healthcare system for billing and reimbursement purposes.

When entering patient claims data onto the CMS-1500 claim, it is recommended to enter alpha characters in upper case. This is because upper case letters are easier to read and less prone to errors or misinterpretation. Using upper case ensures clarity and consistency in the data entry process, reducing the chances of mistakes that could lead to claim denials or delays in processing.

The patient's return surgery is billed as an additional surgical procedure because it is a separate procedure performed to address complications that arose from the original procedure. This means that the surgeon will bill for the additional surgery in addition to the original procedure.

The correct answer is medical practice because the billing entity refers to the entity that is responsible for submitting the claim for reimbursement. In this case, it would be the medical practice that provided the medical services and is seeking payment for those services. The acute care hospital, insurance company, and patient or spouse are not typically responsible for submitting the claim and therefore would not be considered the billing entity.

The provider would need to write a letter explaining special circumstances when a patient's inpatient stay was prolonged due to medical or psychological complications. This is because the extended stay may require additional documentation and justification to the payer for the need of continued hospitalization.

Outpatient surgery and surgeon charges for inpatient surgery are billed as one charge. This means that all the components of the surgical process, including pre-surgical evaluation, hospital visits, surgical procedure, postoperative care, and follow-up visits, are combined into a single fee. This simplifies the billing process for the patient and ensures that all necessary services are covered under a single charge.

A global fee refers to a single charge that covers all aspects of a medical/surgical case, including pre-surgical evaluation, hospitalization, surgical procedure, discharge visit, and postoperative follow-up care. This means that the patient pays one fee for the entire package of services provided, rather than separate charges for each individual component.

The phrase "assignment of benefits" refers to the patient authorizing the payer to reimburse the healthcare provider directly. This means that the provider will receive payment from the payer instead of the payment being sent to the patient. The provider accepts this payment as full payment for the services rendered, and they may not collect additional copayments from the patient.

When an "x" is entered in one or more of the YES boxes in Block 10 of the CMS-1500 claim, payment might be the responsibility of a homeowners insurance company. This suggests that the claim is related to a situation that involves damage or loss to the insured person's home, such as a fire, theft, or other covered event. In such cases, the homeowners insurance policy would typically provide coverage for the expenses or damages incurred, including any medical expenses related to injuries sustained on the property.

An optical character reader (OCR) is a device that is used to view CMS-1500 claims. OCR technology allows the device to scan and interpret the text on the claims, making it possible to view the information electronically. This can be helpful for quickly accessing and reviewing the content of CMS-1500 claims without the need for manual data entry or physical paperwork.