Private Practice: Billing Terminology

You've set up your office, finalized insurance contracts, and marketed your practice. You've scheduled appointments, and seen your first clients. The hard part is done, right? Smooth sailing?

Not quite. Now you have to actually get paid for the services you are providing. That's pretty easy if your clients are self-pay...but many (perhaps most) people want to use insurance if at all possible.

I thought billing an insurance company would be relatively straight-forward: enter some information on the insurer's secure website, or perhaps fill out and send in a form I could download. Nope. It turns out to be quite a bit more complicated than that.

In order to understand billing, you first have to familiarize yourself with key terms and abbreviations. You have to know these terms to even begin to sort out the billing process (which I'll write about it a future post).

1) Information about the Provider
To begin with, you need to know your NPI number (might as well memorize it, really, you'll be using it so often!), and your tax ID number - that is either your personal social security number, or a special tax ID provided if you registered yourself as a company or business (in which case it would be called an EIN - Employer Identification Number). If you are asked to select between S or E, it's asking whether your tax ID number is a "social" or "employer" number.

2) Information about the Client
You will need to know the client's insurance policy member identification number and date of birth. For medicaid products, you may hear the member number referred to as the RID - short for medicaid recipient identification number. You may also need their social security number, address, phone number, and employer. If the insurance policy is in someone else's name (e.g., a parent or spouse) - referred to as the policy holder, or perhaps the guarantor - you will need that person's name, date of birth, and possibly social security number.

3) Information about the Service Provided
You will need to provide the client's diagnosis, with associated ICD code (International Classification of Disease). Yes, just when you thought you had the DSM down, they want you to use a different system. Thankfully, many of the codes in ICD-9 are very similar to their DSM-IV-TR counterparts. I don't know, however, how things will change with ICD-10, which will be required within the next 2 years, and expands the possible length of each code to a maximum of 7 digits. Bear in mind that the diagnosis code determines whether the client is eligible for parity.

You also have to provide a code indicating what procedure (service) you provided. These are called CPT (Current Procedural Terminology) codes, established by the American Medical Association. The insurance company likely provided a list of relevant CPT codes in your contract, specifying the reimbursement rate for each. Ones you should know include:

90801 - Diagnostic Interview Evaluation (i.e., assessment)
90804 - Individual Therapy, 20-30 minutes
90806 - Individual Therapy, 45-50 minutes
90853 - Group Therapy
90847 - Family Therapy, with Patient Present

Note that there are separate codes (not listed here) for therapy including medication management (for prescribing professionals), and codes designated "interactive therapy" - the latter refers only to therapy that is non-verbal, and relies on assistive additions, such as an interpreter or technology for non-verbal communication. Play therapy does not qualify (it is partially verbal).

4) Standardized Billing Formats
All of this information must be encapsulated into a standardized form, to comply with Federal regulations (HIPAA). It seems that specific standards were developed for Medicaid and Medicare, and private insurance companies have decided to apply these standards across the board (I suppose it simplifies things somewhat to use one standard, rather than trying to keep track of different rules for each insurance company).

Paper billing must be done on specific forms called CMS-1500 forms. CMS stands for Centers for Medicare and Medicaid Services. This government agency was previously known as the Health Care Financing Administration (HCFA), and thus the forms were HCFA-1500 forms. The version of the form does change over time, and the current version is 5010. Be sure you are using the right form. Furthermore, the grid lines on the form are red - and must be red for it to be submissible. That means you either need to purchase official forms, or use a computer program and printer that will print it with red lines. Also keep track of your insurance company contracts for any other requirements; for example, one company with whom I contract requires the form be typed (either via a computer program designed for the form, or via typewriter!), in all capitals.

If you want to submit claims electronically, you will need to set up EDI - Electronic Data Interchange - with the insurance companies, to ensure that protected health information is being submitted securely. You will either need access to a secure FTP program (File Transfer Protocol), or use a service of some kind (a topic for the next post on the subject). The CMS-1500 form is still used, but this time an electronic version that has been encrypted in a standard way (referred to as EDI 837, with suffix p for individual providers and i for institutions). If you want electronic notification of the insurance company's response to the claim, you want electronic remittance advice (ERA), which has a formatting designation EDI 835.

That sounds complicated - but it isn't as hard as it sounds, and you don't have to pay for a billing service. More to come on that. Why would you want to learn it? Insurance companies say that it is faster (2 weeks versus 45 days), and has a higher approval rate due to fewer user errors (since omissions and typos may be caught by whatever program you are using).

Please leave comments with any billing tips you have, and any terms I've missed!