Coding & Billing Tools

MedChi has compiled a list of Frequently Asked Questions (FAQ’s) related to billing and coding to help with the claims management process.  If you don’t see the answer to your question please ask a Practice Management Consultant.

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When is a patient considered a new patient?

A patient is considered a new patient to a physician or practice when the physician, or another physician in the same practice, has not seen that patient in greater than three years. 

What is required for a consultation? 

A consultation requires three elements, without all three of these elements the visit should be billed as a new patient.

1. A referral from another physician.  The preferred documentation is a written request from the ordering physician.  A patient who refers himself or herself or is referred by a friend or family member is not considered a consult.

2. A documented history and physical exam of the patient.

3. A written response to the referring physician.  This may be a copy of the history and physical exam copied to the referring physician or it may be in the form of a letter to the referring physician.  Be sure and document evidence that the correspondence was sent.

How do I know if I am billing a diagnosis or ICD-9 codes to the highest level of specificity?

The ICD-9 book has two sections; the first section is used as an index to look up the symptom or diagnosis.  The second section is used to look up the prospective code and verify with the more detailed diagnosis.  This section will prompt you to be specific with the fourth and fifth digits of the diagnosis code.  The fourth and fifth digits of the diagnosis code will ensure that you are billing to the highest degree possible for each patient. 

What is the difference between “risk” and “non-risk” insurance plans? 

When an insurance carrier accepts the “risk” of a beneficiary, they will bill the beneficiary or employer a premium each year.  The insurance carrier than “takes the risk” that the beneficiary will remain healthy and not use benefits above the premium rate. 

A “non-risk” insurance plan is when an employer (typically a large employer with many employees) chooses to accept the risk instead of the insurance company.  Employers may choose this option as a cost savings for their company.  Both risk and non-risk plans can be either HMO’s or PPO’s.  Non-risk plans may also be called third party administrator plans (TPA) or ERISA plans.  The non-risk plans do not follow Maryland Insurance Laws. 

What is the timeline for timely filing of claims? 

Insurance plans that are governed by Maryland Insurance Laws allow a physician to file claims 180 day from the date of service.  Many physicians call when they receive notice that the insurance company is denying payment for timely filing after 90 days.  When an insurance plan is a non-risk plan, they are not governed by Maryland Law and therefore, the timely filing requirements revert to the contract between the physician and the carrier. 

Where can I appeal when I have exhausted all avenues with an insurance carrier? 

1. Risk claims (Those covered under Maryland Law):
Maryland Insurance Administration
200 St. Paul Street
Suite 2700
Baltimore MD 21202 

2. Non-Risk claims (Those not-covered under Maryland Law):
Employee Benefits Security Administration
Washington District Office
1335 East-West Highway
Suite 200
Silver Spring, MD 20910 

3. Federal Employee Claims 
Office of Personnel Management
1900 E Street N.W.
Washington DC 20415-0001