Medical Insurance Billing 101

Since few people ever talk about this, I'll try and put it as delicately as possible: few people complain about Football and Baseball stars making millions and millions of dollars-yet; a brain-surgeon who went to school for 10 years gets the boo for charging $1000,00 an hour to his patients....

In the 19th century, things were simple. When you saw a doctor, you'd either pay on the spot and/or if you were really lucky you'd have an insurance company which would either pay the doctor's office directly, or you.

The current ICD9 (International Classification of Diseases 9) has been around since 1977, and marks the ninth edition in the series. There have been many revisions which have expanded close to 90 years since its first edition appeared in 1893. However and with all this being said, the ICD9 is not only the most widely used, but it's the only one used for the purpose of medical insurance billing.

Diseases are categorized by numbers. The numbers usually read as follows 000.0, for example: Carpal Tunnel Syndrome (CTS) is classified as 354.0. This number is placed on the disease section of the HCFA 1500 form; the HCFA 1500 is the claim form used for the purpose of submitting a claim to the insurance company.

The other component of billing are procedure codes. Where as you need a diagnosis code (ICD9), the procedure code is probably the more important of the two. It is the procedure code which tells the insurance company what services the medical professional provided to you, as well as what he's charging them for. Taking Carpal Tunnel as an example: the physician may suspect you have Carpal Tunnel, but unless he takes an X-ray, how can he be sure of his prediction? The X-ray is the procedure code (what was done). So to reiterate - Carpal Tunnel is the disease - the X-ray is the procedure done. Procedure codes are usually 5 numbers long. Since an X-ray is known as a 7-series code in the industry. It will read as follows: 70000, etc....

The next section of medical billing are modifier codes. A modifier code indicates a procedure was modified. Modifier codes are two numbers long, for example: 50 - this might well indicate that the services were rendered by an assistant surgeon instead of the primary surgeon for example. A modifier 'modifies' the services to indicate a slight change.

The procedure codes also determines what is/and how much is to be charged for the visit or  surgical procedure.  Example - 9-series codes are used for doctor's visits, 99212 etc. Facilities' such as hospitals etc., use different numerical codes for their charge, but everyone has to use procedure codes or they will not be paid.